A medical staff checks on a ventilator of an intensive care unit at a newly inaugurated hospital by the Tamil Nadu state to fight against the COVID-19 coronavirus, in Chennai.
Image: Arun SANKAR / AFP
A little more than a year after India went into its first Covid-19 lockdown in March last year, the country is witnessing its second wave of the pandemic, with an increasing number of cities imposing night curfews, and restrictions on business and movement. Maharashtra, the worst affected state in both the pandemic waves, is currently under night curfews, weekend lockdowns, and severe restrictions on business activities.
As the surge in cases threatens to overwhelm medical infrastructure—hospital beds are rapidly filling up, and ventilators are already in short supply in multiple Covid-19 hotspots—there is a sense of déjà vu. But, there are questions too.
When the number of Covid-19 patients started swelling in March, the government called for Indian companies to step up to the challenge, and manufacture ventilators on a war footing. Picking up the gauntlet was a bunch of established ventilator manufacturers and startups, who rapidly ramped up production capacity, invented entirely new machines, and collaborated with other industry players in unprecedented ways.
By end March, the Association of Indian Medical Device Industry (AiMeD) had reached out to seven of its 10 ventilator manufacturing members, who had confirmed that the total production capacity at that time was between 5,500 and 5,750 units per month. Rajiv Nath, forum coordinator, AiMeD, had said in a press note that the aim was to produce 50,000 ventilators per month by May.
The central government stepped in to order ventilators in bulk from home-grown manufacturers: By June, Rs 2,000 crore had been allocated for supplying 50,000 ‘Made in India’ ventilators to government-run Covid-19 hospitals across the country through the PM Cares Fund. While 30,000 ventilators were being manufactured by Bharat Electronics Limited (BEL), the remaining 20,000 ventilators were being made by AgVa Healthcare (10,000), AMTZ Basic (5,650), AMTZ High End (4,000) and Allied Medical (350), respectively.
There seemed to be a plan of action that was being implemented. However, a year later, the scramble for ventilators has started all over again.
The Second Wave
As of April 8 morning, India witnessed a record single-day increase of 126,789 cases, with 10 states accounting for 84.21 percent of the tally, according to the Ministry of Health and Family Welfare. Maharashtra reported the highest number of daily new cases, with 59,907 cases, followed by Chhattisgarh (10,310 cases) and Karnataka (6,976 cases).
On April 7, Murlidhar Mohol, the mayor of Pune, one of the worst-hit cities in Maharashtra, told news agency ANI, “If the surge in new cases continues, we could have a dearth of ventilator beds. I have written to Maharashtra Health Minister Rajesh Tope and Union Minister Prakash Javadekar, requesting the transfer of ventilator beds from the states where Covid-19 is under control… The number of beds is sufficient in the current situation, but if it goes on like this, then there will be a shortage.” On April 8, the city reported 11,000 fresh Covid-19 infections.
In Nagpur, the situation was already more dire. By the morning of April 7, according to media reports, there were no ventilator beds available in private hospitals; by the evening of that day, only three ventilator beds were vacant at the Government Medical College and Hospital (GMCH), which also got quickly occupied. The report quoted Dr Anup Marar, convener of the Vidarbha Hospitals Association, as saying, “There is an urgent need for ICU beds. This strain [of the virus] is too infectious. Patients who have already taken an oral anti-viral course, have deteriorated and are landing up, in the first instance, in the ICU.”
Chhattisgarh, which had remained relatively less affected in the first wave of the pandemic, is witnessing a surge in cases during the second wave. In March alone, the number of active cases in the state increased by over 1,000 percent, touching a total of 55,512 cases and 500 deaths. Chhattisgarh’s Health Minister TS Singh Deo, in a media report, said that the state was running out of ICU beds, as people struggled to get to hospitals on time. “We have 80 to 90 percent occupancy, and soon we may reach a point where we won’t have beds,” he said.
Punjab is also witnessing a steep rise in the number of Covid-19 cases, and deaths: From a daily average of 240 cases in the second week of February this year, it is seeing a daily average of 2,800 cases in the first week of April. Around 80 percent of these cases are the UK variant of the coronavirus, according to Union Health Minister Harsh Vardhan. “If we look at Punjab, 3 percent of the total cases are being reported from Punjab now and it accounts for 4.5 percent of the total fatalities in the country,” said Union Health Secretary Rajesh Bhushan on April 6.
With an increasing number of patients being hospitalised, and being put on ventilator support, the government has increased the number of beds at hospitals with ICUs, ventilators and oxygen support from 2,175 to 4,539 in Punjab. However, it continues to rely heavily on the private sector to increase bed capacity.
Where are the ventilators?
Last year, after the surge in the manufacturing and procurement of ventilators, what followed were actions and decisions that undid much of the good.
For instance, according to reports, the central government had sent 290 ventilators, worth Rs 20 crore to Rs 30 crore, to Punjab last year, but even by March this year the state’s health department was yet to unpack them for use. Ideally, these ventilators should have been sent to medical colleges or other medical centres that offer level 3 care (equipped with ICU, ventilators and oxygen supply) for Covid-19 patients.
Tanu Kashyap, managing director of Punjab Health Systems Corporation, had said there had been no demand from the state’s medical colleges and other hospitals. The biggest issue for these medical colleges was the lack of trained technicians to efficiently manage patients on ventilators.
“There is a huge shortage of trained staff, and this training has to be done on mission-mode level. Whether this training is imparted online or offline, there is an urgent need to train hospital staff on how to use these sophisticated machines, and to make them familiar with their features and processes,” says Nath of AiMed. “The ventilators are not standard products and each of them is different, with different features. It is like switching from an Android phone to an iPhone; there will be a learning and familiarisation phase.”
Then there is the case of ventilators—made in record time and in record quantities under government purchase orders—that are still lying with the manufacturers. “India Inc had responded magnificently to the challenge of ramping up capacity to make 4 lakh ventilators per annum, up from 3,300 ventilators per annum in 2020,” says Nath, pointing to the CSR support role and collaborations between organisations such as Maruti, MG Motors, Ashok Leyland, BEL, Skanray, IIT Kanpur and Nocca Robotics. “However, orders from the Government of India and state government authorities suddenly petered off after June-July, leaving manufacturers with huge investments and inventories.”
“The government had placed a purchase order for 10,000 ventilators from us in April, 2020,” says Diwakar Vaish, CEO of AgVa Healthcare, one of the larger ventilator makers in the country. “We made this number of ventilators in record time and finished manufacturing 10,000 ventilators by May.” However, it has been a year since then, and the government is yet to pick up half of this order—5,000 machines that are sitting in AgVa’s warehouses.
“Last April, ventilators were a critical element in the treatment of severe Covid-19 patients, and so there was the rush to manufacture them,” says Vaish. “But now there are other treatments as well for Covid.” The company made a total of 15,000 ventilators during the pandemic, of which about 7,000 remain unsold. Manufacturing activities at its plants in Noida and Dharuhera in Haryana have come to a halt. “We want to sell off the current inventory before we start manufacturing any more ventilators,” adds Vaish.
Another leading ventilator manufacturer in India is Chennai-based Phoenix Medical Systems. Its managing director Sashi Kumar V told the media this March that even their first orders placed through the Andhra Pradesh Medical Technical Zone had not been fully picked up yet. “At our Vishakhapatnam plant, we scaled up capacities for producing 500 ventilators a month, but there are simply no orders. We are trying to dilute our inventory of 1,000 ventilators by trying to sell them in ones and twos to the private health care sector,” he said.
There have also been instances of state governments and hospitals complaining of faulty ventilators sent by the central government. Complaints of inadequate ventilators have surfaced in Rajasthan, which had received 1,138 ventilators under PM Cares, and where these machines account for almost 60 percent of the 1,900 ventilators in the state. Following complaints from hospitals, Rajasthan’s Secretary of Medical Education Vaibhav Galriya said, “We took feedback from medical colleges across the state and there was a general complaint regarding ventilators received by the state under PM Cares. Hence, we have written to the Union Ministry of Health regarding the issue.” Doctors have complained that the CV 200 ventilators (manufactured by Bharat Electronic Limited, based on a licensing agreement with Skanray Technologies) and those made by AgVa Technologies are not effective.
Nath, of AiMed, says that if a buyer has a complaint, then they definitely have every right to seek redressal from the manufacturer, and the manufacturer must step forward and address these issues. However, he also adds, “In the initial stages of manufacturing and installing these ventilators in March and April last year, there were more such issues. Subsequently, AgVa and Skanray had been asked to upgrade their software, and they had done so at their own cost. Buyers were then asking for certain features that were, you can say, for a high-end car. It is comparable to asking for iPhone-like features in a low-cost phone.”
Vaish of AgVa Technologies says, “Tertiary care hospitals and top-end hospitals are accustomed to taking in top-end machines and equipment. There are many cases in which they prefer imported machines, which can cost between Rs 10 lakh and Rs 35 lakh. But in an emergency situation such as this, you can’t always get to choose what you get. Our company has delivered machines as per what the government asked for. Our machines cost Rs 1.5 lakh and are portable, so that they can be easily moved around. But this also means that there will be some trade-offs.”
Vishwaprasad Alva, founder and managing director of Skanray Technologies, however, has a different take on the reports of ventilator shortages: “A lot of these issues are actually related to the capabilities of India’s health care system. There is a huge mismatch between the number of intensivists [physicians who specialise in the treatment of critically-ill patients], anaesthetists and trained technicians, and the number of ventilators that were made available by manufacturers last year. In many cases, the shortfall of trained manpower and the health care system’s inability to absorb the ventilators is presented as a shortfall or shortcoming of the hardware [ventilators].”
Alva added that about a month ago, he saw thousands of new ventilators, manufactured through the collaboration of Skanray and BEL, lying unattended and uncovered in the stockyards of district- and taluka-level hospitals. “When I enquired about why the ventilators had not been installed, I was simply told that they don’t work. But when I checked further, I learnt that the hospitals had not even registered any complaint or request for installation with BEL. The health care delivery staff finally admitted that they didn’t want the ventilators since they did not have the specialists, technicians and staff, nor the capability to intubate critical patients at their hospitals. In fact, this hospital that had abandoned the ventilators in an unused storage space did not have the basic equipment and capability to treat even the milder cases of Covid-19 or other emergencies.”
Alva goes on to talk about another large district hospital in Mysuru, very close to Skanray’s facility, which “has a beautiful civil structure, and was inaugurated over a year ago. It has empty halls, no furniture or basic biochemistry labs, forget advanced equipment or qualified staff. The infrastructure is just civil, which, for obvious reasons happens and gets inaugurated with pomp and show.”
Vaish adds that that the second wave of the pandemic, and the surging number of cases, might lead to increased demand for ventilators again. “We have not heard from the government, but the private sector has been very proactive. From a ventilator maker’s perspective, there is a fairly inadequate number of ventilators on the ground, and there is a requirement for the devices. It is also not just a matter of the number of ventilators available on the ground, but also their distribution across cities and hospitals. At the moment, a lot of ventilators are being shifted from one place to another, according to requirements.”
Commenting on the current ventilator shortage that several cities are experiencing, Nath says that the government should have procured and stockpiled ventilators when the number of Covid-19 cases had gone down, and should have been prepared for the second wave of the pandemic, instead of leaving the stockpiles with the manufacturers and expecting them to bear the cost of the machines.
Alva shares a similar sentiment. “It is not just about the second wave of the Covid-19 pandemic. The government needs to be prepared for emergencies that might need a sudden surge in ventilators. It could be another pandemic in a few years’ time, or a war, or border hostilities. At the moment, there is no preparation for disasters of this sort. No private hospital will ever invest in a future emergency at the cost of investing in a current one. It is the responsibility of the government to build up and maintain a stockpile of about 60,000 ventilators, which are already purchased, and supply them all over the country so that they can be rapidly deployed when needed. If they do not keep these units in hot-standby mode, with periodic monitoring and repairs, this stockpile will be rendered useless when needed.”