End Of A Hospital-Based Health System?

The ravages of the COVID-19 pandemic continue to reverberate globally well into its fifth month. In its tragically destructive trail lies nearly a million cases and 50,000 deaths in 180 countries. The human impact – physical, psychological and social – of the pandemic is only just being assessed and the true cost of this great human tragedy will take years, if not decades, to fully quantify. Amongst the various scenarios that were posed in the early stages of the outbreak – some cheery, some very optimistic now seem well forgotten. The thinking now veers more towards the gloom-ridden end of the outcome scale. The international global tragedy has had galling national subplots which are beyond any tragedy that the human race had to face in living memory. Many talk about the Plague, the Spanish Flu, the Great Wars and the Great Recessions, our generation got its unbidden Great Pandemic.

In these most uncertain of times, a definite certainty has emerged. Life, and many aspects of it will not reset to their original setting. This while true in aspects of our day to day lives, will be most true for healthcare and health systems. The pandemic has revealed the underbelly of the postmodern health system created in the 20th century, which is proven inept for the challenges of the 21st. The multiple health challenges of the 20th century  – tuberculosis, smallpox, polio, malaria and others required large physical infrastructure to adequately treat and manage. The latter part of the previous century witnessed the rise of vector borne diseases, virus transmitted diseases like HIV/AIDS and non-communicable diseases like cancers and heart disease. Once again the health system built in the decades earlier, proved adequate to take care of this disease burden.

The 21st century poses a major shift in our thinking of health infrastructure, its nature, type and setting. With a rise in non-communicable diseases, many of which require ‘lifetime management’ as opposed to episodes of care, the current clinical settings seem inadequate. Add to that the unmanacled threat posed by epidemics and pandemics like COVID-19, SARS, H1N1, Ebola and others, and the need for a paradigm shift proves necessary.

The shift towards the use of real-time, location-agnostic monitoring technologies for individuals and disease outbreaks will become an important tool in a new system. The use of telemedicine and e-health, not novel by any means, will find an expanded role. Similarly, at-home care, by-home caregivers (the AHC-BHC model) will be further strengthened and protocolised. Public health measures like lockdowns, isolations and quarantines will also necessitate the need to localise care hotspots within the community. Therefore, the rise of modular health infrastructure appropriate to the local community needs, based on its demographic and health needs profile will become the new norm.

This shift in clinical setting, away from the formal hospital, will be determined by the three S’s – state and stage (of the individual and disease) along with stratification of the risk posed – to the individual, location or community from the nature of the disease – will determine the clinical setting of the medical response required. So, while higher end spectrum of care viz. cancer care, heart surgeries and organ transplants will continue to see the current clinical settings, many other conditions will be dealt through varied models.

For patients, caregivers and the community, this change will need to be harmonized over time. A blend of the existing and the proposed new, will need to continue for a period of time before the paradigm shifts. For policy makers, the myth to associate only brick and mortar with health infrastructure would need a radical re-think. The end of the hospital is certainly not nigh. But the era of the hospital as the primary means of care, may well be over.

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