Workers and homeless people wait on the Yamuna’s banks as they wait for word about a shelter, shortly after India extended its nationwide lockdown, in Delhi, April 2020. Photo: Reuters/Anushree Fadnavis.
The COVID-19 pandemic has foregrounded an issue that plagues healthcare and yet is rarely discussed: rationing in the provision of healthcare.
When COVID-19 death rates peaked in Italy in March, TV channels flashed horrific images of desperate patients lined up in hospital corridors awaiting admission, even as overworked healthcare workers triaged the arriving rush. It isn’t as if the doctors had a playbook to make decisions about who got a bed and who had to be sent home. They had to extemporise on their feet, knowing fully well that some of those sent home would die.
The arrival of COVID-19 in India in late March sparked fears of a cataclysmic crisis given the inadequacy of the health infrastructure, the largely poor living conditions and the density of population. In Maharashtra and Delhi, the worst hit parts of the country, ventilators, ICU beds, nurses, doctors and medicines were all in short supply at different points. Some patients died while shuttling from one hospital to another in search of a bed. But fortunately, many of our worst fears have not come to pass – perhaps more due to luck, since the fatality rate in India has been lower than expected.
Now, with the imminent launch of a vaccine, the next phase of COVID-19 related rationing will soon come to be. The vaccine is manufactured in batches, so an instantaneous roll out to the entire population is impossible. The initial vaccination campaigns have to target those most at risk – the elderly and the healthcare workers. Some who are eager to be vaccinated so that they can safely return to work will have to wait. If it is simply left to the market, vaccine supplies will be cornered by the rich and the powerful. There may even be a black market in vaccine supplies. To avoid these problems, we need to carefully plan and execute the rationing of initial supplies.
Pandemics are black swan events. In ‘normal’ times, the availability of healthcare services should be sufficient to meet demand and everyone should be served. The reality is quite different – not just in India but even in the OECD countries.
But what is less appreciated is the fact that in countries like India, even before the pandemic struck, healthcare was rationed because of the inability of public health resources to adequately meet demand. While this can be compensated to some extent by increasing spend and reducing wasteful expenditure, the truth is that even under the best circumstances, healthcare will have to be rationed. The impact of rationing can be mitigated if it is done in a planned, rule-based and transparent manner, so that the poor and voiceless are not deprived of their fair share of what the nation spends on the health of its citizens.
Rationing beyond COVID-19
The US spends the most among all countries on the healthcare of its citizens. Despite this, about six million Americans don’t have health insurance. They find it difficult to get routine care and hence have to wait until their health has worsened sufficiently for them to be eligible to be treated in emergency wards. As a result, some 26,000 Americans die each year, according to a 2008 estimate.
In countries like Canada and the UK, which have implemented socialised health care, routine outpatient care is available on demand, but elective procedures like joint replacements are accessible only after a waiting period that can last as many as six months. The enforced immobility due to a joint problem can in the meantime cause other health problems, and some patients may die waiting for surgery. A Canadian supreme court judge quipped in 2005 that “access to a waiting list is not access to health care”.
Rationing healthcare in countries like India is like an iceberg: much of it is invisible. The poor in India depend on free care provided by government hospitals. But such care is extremely variable, both in quantity and quality. There are long waiting lists for surgical procedures. Costly medicines are only available on and off, and doctors often have to choose who will get the medicine and who won’t. Many poor patients are too illiterate to know that they are being provided substandard treatment due to a shortage of equipment and medicines. They don’t have a choice and they accept what they are given. This situation is so commonplace that it is too banal to be covered in the news. A million Indians die each year because of an inability to access care.
If everything was equal and receiving costly treatment at a government hospital was simply a matter of standing in line, it may still be a fair system. But extraneous considerations often influence who gets treated and who doesn’t. How healthcare resources are apportioned also depends on gender, age, socioeconomic status and caste. People close to power appropriate precious resources out of turn, precipitating even greater misery for those unfortunate who don’t have a voice in the corridors of power.
If the shortage of healthcare supplies and services, and inequity in their distribution, is bad now, it’s only likely to get worse. Specifically, three drivers will increase the pressure to ration healthcare in India’s near future.
Impact of rationing healthcare
For one, medical and technological breakthroughs are being produced at a breakneck pace. Many of the new treatments are far superior to existing ones – but such innovation comes at a price. Novel anti-cancer treatments can cost lakhs of rupees. An Apollo Hospital in Chennai has installed a proton-beam therapy machine, and treatment for one patient costs Rs 20-30 lakh. It is impossible to imagine a scenario wherein the Indian public health system – even in an idealised future – can make such procedures available for free to all who may benefit from them.
The second driver is India’s demographic transition. More Indians are living longer – but not necessarily in good health. Among the world’s countries, Indians spend the longest period on average in sickness towards the end of life: 15 years. Much of this is likely to be expensive hospital-based care that strains our resources further.
The third driver that will compel rationing is the promise of the Government of India to move to a system of universal health coverage. This should be accompanied by some increase in the government spend on healthcare. The government itself has promised to double healthcare expenditure to 2.5% of the GDP – but this won’t suffice to cover a minimum acceptable standard to all those who depend on free care at present. In response, the government will have to even more tightly enforce rationing norms.
Rationing is inevitable, so can we make it equitable?
First, if rationing is to be implemented, it has to be based on a set of rules rather than becoming the arbitrary choice of a frontline healthcare worker. Having sound rationing rules will also protect frontline workers from blame when rationing decisions come to favour one group over another.
A rules-based rationing system in turn has to be grounded in certain principles. The first is that the value of a life can’t be based on social and economic considerations. The life of a poor person is worth as much as the life of a rich person, and the life of a woman is worth as much as the life of a man. These principles bear repeating because, in practice, decision-makers often violate them.
With such non-negotiable principles in place, we can then create a set of rules that account for local considerations.
A simple rationing technique that is consistent with this principle and is also easy to implement and resistant to corruption is a lottery system, whereby officials randomly pick those who can avail treatment. The problem with a lottery system is that it is blind to many other relevant considerations. For example, it won’t distinguish between an 85-year-old in poor health and who has only a few more years to live, and a 45-year-old with several dependents who is otherwise in good health. If both need an artificial joint replacement surgery, it is easy to see that when resources are limited, the 45-year-old should get preference. The lottery system won’t take such considerations into account.
The same can be said of a first-come-first-served system, which will favour those who live near a healthcare facility or those who have the means to get there quickly – usually the rich. It can also be manipulated by those who have the power to influence the queuing system.
A more common rationing rule is to prefer those who are sickest – as is already the case with organ transplants. While this rule will work well in a variety of situations, it may not be the best answer when a health-status assessment is based on the subjective impression of a doctor and when the sickest patients also have the least chance of benefiting from the treatment (since their health is so compromised that a full recovery is unlikely).
Another common rule is to treat those who are younger and so have the longest life expectancy ahead of them. For example, treating a cancer patient who is 20 years old with a curative but expensive treatment might be preferable over treating someone with the same condition who is 65 years old.
Healthcare workers, hospital administrators and government policymakers can consider many other rules. But the point is that the decision-making algorithms have to be thought through, and the government has to implement them transparently, and subject to periodic audits. In fact, once a decision-making rule-set is ready, a technological solution could help eliminate simple points of failure. For example, the government can implement a system that uses information extracted from electronic medical records to generate composite eligibility scores that will determine, or guide, who is to be prioritised. Then again, this is easier said than done, with considerable thought and even some supervised experimentation.
Consultation with civil society
The ethics and practical considerations that should govern how healthcare is to be rationed are complex, and have to account for the local context of the community and the hospital where rationing decisions are being made. So it’s important to involve members of civil society to participate in the rule-framing process, so that officials can settle tricky ethical issues at the outset with their inputs.
Implementing a rationing system that is a black box will not fly in a system where democratic self-governance is the norm, especially since the issues aren’t purely of a medical nature. Any rationing system will create winners and losers – but the rationing decisions themselves will have to optimise outcomes for society as a whole.
For example, if a system from treatment those who may not benefit from intervention, then it would free up medical resources – beds, doctors and nurses – for patients who have the highest chances of benefiting from intensive medical interventions. This would be a way to free up resources that may otherwise get locked up in Sisyphean medical efforts that keep a life suspended in limbo between health and death.
Importantly, a system to ration healthcare can’t function independently of those who are responsible for implementing it. Doctors in government hospitals always struggle with rationing decisions, and some get it better than others. It’s always tempting to buy the best equipment although the same amount of money could save more lives when spent on scaling up a lower tech approach to treatment.
Dr R. Venkataswami, a renowned plastic surgeon at the Government Stanley Hospital in Chennai from the 1970s to the 1990s, ran a world-class hand surgery unit that he built from scratch. At a time when microsurgical reattachment of amputated fingers and thumbs was becoming more popular, he was confronted with a choice: to offer microsurgery as a first-line option or reserving it for those in desperate need, e.g. those who needed a reattachment of the thumb, a vital digit. While the temptation must have been great to focus on the former, Dr Venkataswami knew that it would come at a steep cost: the inability to treat every patient, since microsurgery soaked up a disproportionate amount of departmental resources. A surgeon would spend upwards of six hours for each such surgery.
So Dr Venkataswami made the conscious decision to limit microsurgery for cases where a critical hand function was at stake, and for the remaining patients he resorted to more standard techniques that could be performed quickly and with fewer resources. By doing this, he didn’t have to turn away a single patient coming to the department.
This kind of holistic planning and resource prioritisation has to be standard training for all doctors, to prepare them for a world in which healthcare resources will be a zero-sum game. One patient’s costly treatment will be another patient’s inability to get treated. We may be putting it rather bluntly, but that is how it is.
Given the difficult ethical choices imposed on rationing decisions, it’s imperative that the overall healthcare delivery system is efficient and productive, so that we can minimise the need to ration. Our public health systems are a far cry from this. By reducing waste, containing fraud and eliminating errors, we can take a big bite out of healthcare expenditure that can be reallocated to care that is necessary.
Big or small, the resources for healthcare are ultimately finite – but the demand for costly new treatments is growing rapidly. It is critical for us to focus and extract the most out of our healthcare allocation so that the pain and deprivation imposed by rationing are mitigated to the extent possible. Having done this, we should then install a simple, transparent and easily implemented rationing mechanism that will restore faith among our poorest and most deprived citizens.
Swami Subramaniam is the author of Healing Hands, a hand surgeon’s biography. Aparajithan Srivathsan is the managing director of Intent Health Technologies. They are joint authors of the book Hospital 5.0, to be published in 2021.