Successfully treating severe cases of COVID-19 - whether by oxygenation, the administration of steroids, or the use of ventilators - often requires a patient to be hospitalised. Since the number of beds present in a healthcare system constrains the number of patients hospitals can treat, maintaining sufficient bed capacity is an important part of reducing deaths from COVID 19. The Brihanmumbai Municipal Corporation (BMC) chose to supplement beds in public hospitals by constructing jumbo field hospitals and requiring private hospitals to set aside a certain percentage of their beds for COVID patients. Beds from all three types of facilities were allocated to patients by BMC task forces called “war rooms” set up at the administrative ward level. These war rooms were staffed with municipal government workers and were tasked with tracking all COVID-positive patients in an administrative ward and managing bed allocation among these patients.
Using data released by the BMC, this analysis makes two arguments that explain why private hospitals contributed a small share of Mumbai’s COVID bed capacity. First, the BMC focused on requisitioning primarily those types of beds from private hospitals which were in short supply and difficult to scale up (ICU beds, oxygen beds), but not those which public hospitals had a sufficient supply of or were easy to scale up (non-ICU beds). Second, the BMC focused on requisitioning private beds primarily during crisis times when public bed capacities were limited and falling, but allowed private hospitals to use their beds as they wanted during low caseload times.
Too few private beds?
At first glance, the proportion of COVID beds provided by private hospitals in Mumbai seems surprisingly low. Private hospitals provided over 70% of the total hospital beds in Maharashtra in 2018, and equal shares of Mumbai’s residents used private and public healthcare facilities in 2019. Despite this large role in Mumbai’s healthcare system pre-pandemic, private healthcare facilities contributed, on average, only 22% of Mumbai’s total COVID beds between July 2020 and July 2021. However, there is significant variation in these shares over time as well as across bed-types1. Exploring this variation sheds light on Mumbai's bed management strategy.
First, although private hospitals played a distinctly secondary role in treating severe (but not life-threatening) COVID cases, they were crucial to the effort of treating the most life-threatening cases and minimizing deaths. This is made clear by the sharp difference in the proportion of ICU and non-ICU COVID beds that are provided by private hospitals. While private hospitals account for only 18% of Mumbai’s non-ICU capacity, they supplied 48% of the city’s ICU bed capacity, on average. Moreover, an average of 30 % (and a maximum of 44%) of all beds equipped with oxygen were provided by private hospitals.
Second, the COVID bed capacity at private hospitals has varied significantly over the course of the pandemic and, in particular, saw a sharp uptick during the second wave of the pandemic. Bed capacity in private hospitals increased from just 16% of the total in early February when the caseload was low, to over 25% of the total in mid April 2021 during the peak of the second wave. Moreover, private ICU capacity increased from 36% of the total in February to over 50% in April during the peak of the second wave. In fact, private ICU capacity was lower than public ICU capacity throughout the pandemic up until the second wave, when private ICU capacity more than tripled between March and May and overtook public capacity.
Evidently, the BMC adopted the strategy of maintaining a large base of public ICU and oxygen bed capacity and supplementing it with private ICU capacity during times with high case-loads.This allowed private beds to be used for other purposes during times of lower case loads. They achieved this by altering the number of beds private hospitals had to set aside for COVID patients depending on the severity of the pandemic. For example, on March 29 BMC issued an order requiring 100% of ICU beds and 80% of isolation beds in private hospitals to be set aside for COVID patients. Consequently, as the number of vacant ICU beds in public hospitals fell during the second wave, private ICU beds were requisitioned to augment public capacity. Previously, when the number of vacant ICU beds had risen between November 2020 and March 2021, the BMC had ceded control of beds to private hospitals, allowing treatment for non COVID illnesses.
Viewed like this, the way in which the two sectors complemented each other was key to the pandemic response. Absent either the stable public capacity or the ability to appropriate the elastic private capacity, bed shortages would have been even more severe in the second wave than what was experienced. Analogously, the division of bed types between public and private sectors was driven by the comparative advantages of each sector. For example, the BMC operationalized large scale jumbo field hospitals at short notice during the second wave because of the government’s ability to mobilize non-ICU beds and basic medical supplies at scale. In contrast, where it was much harder to scale up critical medical supplies supply(as in the case of ventilators and ICUs), private hospitals’ large existing stock came into play. As a result, BMC requisitioned a larger share of ICU beds than non-ICU beds from private hospitals.
In conclusion, a significant portion of the explanation for the private sector’s low contribution to COVID bed capacity can be attributed to the BMC’s strategy of appropriating private sector capacity particularly of those types and in those times where public capacity was low. This strategy involved private sector capacity scaling up and down in tandem with the scale of the pandemic and the BMC appropriating primarily ICU and oxygen beds from private hospitals. This allowed the healthcare system to balance the competing priorities of maintaining sufficient capacity to deal with a covid surge and treating patients with other serious illnesses.
About the Data
The Brihanmumbai Municipal Corporation (BMC) started releasing a detailed daily PDF containing information on a variety of indicators such as mortality, containment zones, bed capacity, vaccinations, etc. from June 2020. Such data is extremely useful not only for formulating short-term policies but also for assisting longer-term academic research. A long-standing issue with using the data, however, has been that the authorities replace the PDF each day with fresh information and remove the prior day's document. This practice has limited any kind of temporal analysis till now. At IDFC Institute, we have been able to gather all such PDFs from June 2020 until the present. We are in the process of converting all relevant indicators to a machine-readable output and will put them out as a public-facing database in due course. In the meantime, we will put out a brief analysis of them along with the related datasets. In our previous posts, we discussed vaccine uptake and equity, COVID-19 mortality data for Mumbai, COVID-19 testing data, containment zones, spread across age and gender and bed capacities.
1. The BMC reports bed capacity by two categories- ICU beds and Normal (non-ICU) beds. Within ICU beds, they report the number of beds equipped with ventilators and within non-ICU beds, they report the number of beds equipped with oxygen.↩