 After several reports of attacks on healthcare workers across India and a symbolic protest by the Indian Medical Association, which was called off, the government has swung into action. The Cabinet has moved to protect healthcare workers who are at the forefront of the battle against the COVID-19 pandemic. It's cleared an ordinance that makes any attack on healthcare workers a cognisable and a non-bailable offense. The ordinance says that any person found guilty of such an attack after a 30-day investigation can be sentenced to up to seven years in prison, depending on the severity of the attack. The guilty will also face a fine of up to 5 lakh rupees and damages to the tune of two times the market value of the medical goods damaged in the attack. The Cabinet has also approved a 15,000 crore rupee India COVID-19 emergency response and health system preparedness package. This will be utilized in three phases. From the package, over 7,700 crore rupees has been provisioned for immediate use. The rest will be drawn upon as needed over a period of one to four years. So, an ordinance there being cleared by the union cabinet. Outside of that, we now have the coronavirus count moving closer to the 20,000 number, though the recovery rate is also fairly positive at about 17-odd percent and over 600 people dead. Joining me now to discuss this and the other issues faced by the healthcare sector, Viren Shetty, the executive director at Narayana Health, Dilip Joes, the managing director and CEO at Manipal Hospital and Abhay Soy, the chairman of Max Healthcare. Gentlemen, appreciate you joining us here on the program. Abhay, let me first start by getting a reaction from each one of you on the ordinance that's been passed by the government. The Indian Medical Association had decided that they would do a black day, so to speak, but that has now been put off the government bringing this ordinance to try and ensure protection to healthcare workers. Will this deter the kind of incidents of attack and assault that we have seen? Well, I certainly hope it will be a deterrent. It has been a long-standing demand of the industry, of the doctors, because even prior to COVID, there have been many, many incidents in the past where healthcare workers, where doctors, nurses and so on and so forth have been manhandled. And this doesn't only happen at the place of work. And I think even today, a lot of them are being stigmatized in their colonies, in their residence associations and so on, where the families are stigmatized. I think this would certainly happen that as well. So it's not only violence against them at the place of work, but also in their place of residence. So I think certainly it will be very helpful. It will help be helpful. Hopefully it will deter the attack and the assaults. But the largest stigmatization of the healthcare community is also a cause for concern. Viren, what will it take to try and ensure that there is better understanding, that there is empathy? Because we've seen cases across India where doctors have been forced to move out of their homes with their neighbors coming out against them. We've had some state governments actually providing accommodation to doctors outside of residential areas in hotels and so on and so forth. What will it take to try and bridge this deficit of information, to try and create empathy in a culture that allows healthcare professionals to get on with their jobs? Just what you said, it takes time. There is a deficit of information at the moment. People are scared, justifiably so. In a lot of the places we've seen a tremendous amount of help, support and outpouring of love for the doctors. And there are places where people are reacting from a place of abject fear. Where we do condemn these incidents as and when they come, there was an incident in South India, for example, where a doctor's family, they refuse to get his body cremated. And that was a horrifying experience for his family. But as of when the media does their rightful role of highlighting these incidents, a sense of collective shame comes across society. And we are glad that the government and a lot of civil society has come together to express their support and to condemn these as isolated incidents. I wouldn't say this is a trend. I would just say that these are one of the instances, but we have to strongly address them. Yes, we do have to strongly address them. Dilip, you know, as the media does its part in being able to take this message across, the government is today clear this ordinance. What about the medical fraternity itself? Because there is panic, there is fear, there is misinformation. What can be done by the medical fraternity as well to try and bridge each of these deficits to ensure that we don't see these aberrations as we're in. Informing the whole state about what has happened well, what are the concerns, what are the next steps. I think that's a good model for the country to follow. Yes, I couldn't agree more with you. In fact, it's, you know, today we've got information that that daily press briefing that the health ministry and the ICMR were doing will no longer be a daily briefing. It's probably going to be a thrice a week is what we're given to understand. But the need of the hour in fact is more communication and more transparent communication to bridge these issues that you speak of. But Abhay, let me get a sense from you now on how the healthcare infrastructure is coping with what we are seeing on the ground today. Case is now coming up to about 20,000, but the recovery rate at about 17% according to the government is also a positive indicator. The fatality rate at this point in time is also fairly low. So what are you seeing on the ground within hospitals? I think let me give you a very interesting analysis. At least this is what my analysis is at this point in time. Now, when it comes to mortality rate, the mortality rate is largely in co-morbid situations. Now co-morbid situations can be passed off as COVID or would be due to the co-morbidity itself. So I mean, I don't know how accurate that data would be from a COVID perspective alone. When we look at the number of infected patients, which is essentially a denominator when we are looking at any ratios, then clearly the number of tests which have been done have been woefully inadequate. One just has to decide on what factor to apply, but the total number of infected patients out there would certainly be more than what has been discovered so far. If I look at hospitalized patients in India, we have been hospitalizing patients which have been asymptomatic and also mildly symptomatic. In any of the parts of the world, these patients would ideally be at home and would be quarantined at home. On the other hand, you've got patients who are reticent, who are not prepared to go into hospitals, and even if they're mildly symptomatic, are basically taking care of the disease at home. But the tourist data that I find in this whole scheme of things is the number of critical care beds which are occupied. Because look, whether you want to go to a hospital or not, if you're critical, you're going to go to a hospital. If I look at this number, in all of Delhi, there were 35 critical care beds which are occupied by COVID patients. In Mumbai, there are 45. As a ratio of the total number of people who've been discovered and infected in these cities, and of course that number is much lower than what the actual number should be out there, it's about 1.2, 1.3 percent, which again is a statistic which is way lower than what it is anywhere else in the world. So although we are seeing a lot of infected cases and I'm sure there are a lot of more infected cases out there, the amount of patients who are critical out of there are really small at the moment. So I mean, one doesn't know if this is because of BCG, because of heat, because of the demographic dividend that we have or whatever else. But I mean clearly this is something which is positive at this point in time. Yes, that certainly is positive and you're absolutely right. The critical care patients or the critical care beds, as you point out, are on the lower side. We're in, forget whether it's COVID or whether you've been tested or not. To Abhay's point, if you require serious medical attention, if you're suffering from a significant respiratory problem, you will find your way to a hospital. Now, in the last month, have you seen any significant pickup in the number of people coming to hospitals to try and see whether they can be addressed in some form or fashion if they do report a respiratory issue? No. In fact, there's been just a general drop across the board for all hospitals, not just for an edge, but every single hospital in India are operating at possibly 20, 30, even 40 percent of what they used to be. We have not seen any spike in cases coming with respiratory distress. We've not seen any abnormally large number of cases that are flood-elected cases right now. And today's postponed elective case becomes tomorrow's emergency case. And there's only a certain number of weeks beyond which these electives turn into emergencies. Yes. And that is a valid point that you make. Dilip, to the point that was being made both by Abhay as well as Viren, that perhaps the situation at this point in time is under control. It's manageable. There is no state that's reporting a lack of beds or running out of capacity to cater to the number of patients. To Viren's point that we now need to reopen OPDs, we now need to look at taking on patients for elective surgeries, etc., which have been put off so that we don't have a larger problem later. I mean, many people saying they're not being able to get to a dialysis center because those are inaccessible. Now, does there need to be a review given where we find ourselves on the COVID curve? Yeah, I agree, Shereen. But one issue we need to keep in mind, certainly we need to open up the hospitals to take care of, particularly ill people, maybe on-course surgeries, maybe cardiac procedures, maybe neurosurgery. But one aspect to keep in mind is the high proportion of asymptomatic patients who are out there in the society. We have seen in the last two weeks multiple instances of atypical presentations of COVID. People come for completely different issues and then turn out to be COVID positive. So one aspect we need to keep in mind is the currently the testing regime in India does not allow elective testing. The criteria is strict about who can be tested. So if we need to open up the hospitals for elective work, I would imagine the testing criteria also would need to get opened up. Yes, that is an important point. And you're absolutely right about the asymptomatic patients who are carriers. But Abhay, now what does it mean as and when we start to see this reopening up of the health care sector? What will it mean in terms of how you are going to be able to cope with asymptomatic patients, put enough checks and balances in place so that you don't have a larger problem going forward? How are you dealing with that? What are the systems that you're putting in place to COVID proof yourself, so to speak? I think there are a few things which are happening. Not only hospital systems, but I think all doctors, all manufacturing, we eat any other industry as well. There's going to be a new way of working. Clearly, why we say the number of critical patients are less, the number of infected patients are growing and gradually growing. So that's going to be life with it. We just have to ensure that we are screening a lot more. We are a lot more focused at the time of triage when patients are entering the hospital. We are screening our own health care workers and ensuring that we testing them and screening them, ensuring that they are spreading it to each other, to the patients, or taking it back to their communities as well. So one has to be cautious about how one is going to be approaching these. We'll have to treat confirmed patients. As confirmed patients, we'll have to treat the suspected patients as confirmed patients as well. So what I see happening is essentially two folds. One is there's going to be a lot more care, which is going to be provided at the same time. You're going to have a situation where some amount of the healthcare workers may still be infected and therefore quarantine. But due to all of these things, essentially the cost of care is going to move up. That is my larger concern in the meeting below that. Okay. The cost of care is going to go up. But gentlemen, is there clarity? Is there uniformity? Is there consistency on the guidelines of what happens if you do have a COVID-confirmed healthcare worker on your premises? Because one of the concerns that industry is raising with the government that you cannot have punitive measures like announcing a seizure of three months of a factory if one person were to be infected with COVID. So what is what is the guideline as far as hospitals are concerned? Is there uniformity, consistency, clarity? We're in. Yeah. See, there were some major reactions in Karnataka and Maharashtra where if a few patients were slipped through the net completely asymptomatic and managed to infect doctors that the entire hospital would close down. That is absolutely not practical in a country like India where we have such a shortage of beds. Hospitals like ours have good protocols in place. The minute we detect an asymptomatic carrier, we isolate, we screen and we quarantine the doctors. But the operations must go on. There are well-established guidelines for doing that. While initially there was this sort of complete lockdown mentality among the policymakers, I think now they've begun to understand the nuances of this. And so I would say you cannot have punitive measures against the hospital because this is something we are going to have to live with for a long time. This is at the end of the day a very mild disease. A lot of people who are younger will show no symptoms whatsoever and may not show up in any fever screening and may even show negative on the test only for it to reappear much later. So you cannot penalize a hospital if it just so happens that certain healthcare workers get the disease. What we do is we've had it happen in our hospitals, we quarantine the doctors close by, we treat them, they get better, they have antibody, they have resistance and they can get back to work. And that was most important this time. Dilip, to the point that was being made both by Virene as well as Abhay and I want to get your take on that. As we move forward, what is this going to mean now in terms of cost of care and as hospitals beef up their own guardrails, their own security systems to try and ensure that there is no, you know, there's no sort of spread even if there were to be a patient or a healthcare professional infected. You know, in terms of PPEs, in terms of the other sort of infrastructure, has there now been a significant ramping up? Yeah, yes, Virene, I think the cost of care would generally go up in the current situation because given the asymptomatic spread out there in the society, we would end up considering every patient as a COVID suspect and put in place all safety mechanisms to deal with that. That would mean, of course, PPE is one and the social distancing that we would need to keep between patients even in hospital. So that would bring down the effective capacity of hospitals. And also, given the same situation, we might continue to find people postponing optional or elective work further. So the hospitals would continue to find it difficult to manage their cost. And till that is clarity on, you know, testing and also the ability to screen more patients. Right, gentlemen, I am going to slip into a short break, but I do want to talk about the health of the healthcare system itself because these are trying times not just for industry, but also the healthcare industry. We'll come back and discuss that in just a moment. Don't go anywhere. Welcome back. We're discussing the state of the India's healthcare sector on account of COVID-19. Let's talk about the health of the healthcare sector. And Virene, let me start by asking you, each one of you have said that occupancies are actually down and they're down quite significantly. You're seeing an average occupancy of about 20 to 30%. What is that going to mean in terms of cost of care? What is it going to mean in terms of salary cuts in terms of being able to hold on to people, working capital requirements, debt? How worried are you today? We can do, we're working with our suppliers to see if we can extend the days of credit. We're working with equipment companies to see if we can defer the payments because at this point, all of us are running dangerously low on day-to-day cash. Okay, running dangerously low on day-to-day cash. Abhay, let me get a status check from you as well. Are you also looking at how you can reduce costs, whether administrative costs, salary costs, seeking deferrals from suppliers, etc., like Virene pointed out, what's the road ahead looking like? Essentially, we have to survive to serve, is what I say. We are in a peculiar situation at this point in time. While most sectors across the world have been impacted because of COVID-19, the peculiar problem that we have and the other sectors have essentially brought their operations. The peculiar problem that we have is at a time while our business has got essentially impacted, we had to ramp up operations. We had to ramp up operations at a time when supply chains have been disrupted, the cost of our inputs has gone up significantly, and so on. In our case, we have volunteered to offer main hospitals out of 17, the flagship in Mumbai and Delhi as COVID-19 only hospitals. What that essentially means is not only the costs of personal protection equipment, but also staff welfare costs. Our entire staff works for 14 days and then it's going to be quarantine for a period of 14 days, and thereafter it goes home. So not only are you paying your salary three times over, but you're also looking after staff welfare at a time where all your input costs, etc., once are articulated through the roof. This, while the rest of your operations, your occupancy like Virene said has gone down by about 70 or percent. So we are operating at an occupancy level of about 35-40 percent at a time like this. So yes, it is the time of shortages. We are under, like every other has kept there, there is financial stress and we're looking forward to the government to provide a lifeline to us as well. What is it that you seek from the government by way of this lifeline that you just brought up, Abhay? So one has been a long demanding of us, has been long standing one, has been GST. So while there is GST on all our inputs, there is no GST on the outputs to that one. Secondly, 70 percent or 60 percent of business of most players is CGHS or CHS, which is really ex-servicemen and central government employees. And this is business we of course want to serve and going forward, whether it is COVID or not COVID, the cost of that care has moved up. So what we are seeking is at least some sort of revision in those numbers, just for the person protection equipment and the additional costs that we are incurring. The same goes with insurance companies. We need to revise our tariffs with them because, like I said, the cost of care has moved up and there are no two ways about that. So we just kind of relook at the whole model. We need to relook at the entire price infrastructure for us to stay afloat. Business is another... Okay, you are using to stay afloat. You mean things are as bad as that? It is very bad across the sector. Dilip, would you agree that it is as bad as Abhay is making it out to be that you require urgent intervention, not just from the government, but also renegotiation of tariffs with insurance companies, etc., to be able to stay afloat? And if that is the situation as far as large chains like MACS and Irina Health and Manipala Concern, what about the smaller players? So, Shrin, you are absolutely right. We are already finding smaller nursing homes and hospitals in smaller towns and tier two towns shutting down. We have seen instances in several of our geographies where nursing homes are closing down with the day's notice. And what happens is at this important juncture, that is taking away a significant part of the healthcare structure's capacity. So people who could be managed in smaller facilities are then ending up in larger hospitals, which should be concentrating on life-saving issues and also management of COVID. So staying afloat is already... Many, many small hospitals are already past that situation, Shrin. And for the larger hospitals, it's a game of managing cash for the next six or seven months. All of us hope that the first is to collect the money that are owed to us, mostly from the government, including income tax refunds. Thankfully, the government is in a positive frame of mind. We serve you both. So that is one inflow that we expect. Many of us have utilized RBI moratorium on servicing of our debt. Like you know, most hospitals is a high fixed cost enterprise, maybe about half the cost is on account of people, our doctors, our staff, and our outsourced contractual employees. The second largest element would be on lease, many hospitals function out of lease premises. And the third one would be managing our equipment, the annual maintenance contract and repairs and maintenance. So we are already in touch with our business associates with respect to some deferment of waiver of fees like rentals or maintenance charges. As far as salary costs are concerned, we have taken a pay cut in Manipath. The senior management team has taken a pay cut mostly to signal the intent that this is a serious issue that we need to come together and sort out. We would not want to, at this point of time, impact our nurses or our outsourced workers because they are the friend line people helping us manage the COVID. And also for an outsourced employee like a security guard or a housekeeper, if we cut those contracts or reduce the head counts, in pretty much no time there is no food on the table for many of them. So that is something we would want to wait and watch for the next couple of months before we take a view on that. Well, absolutely. At this point in time, those in the front line, the least or the last thing that they need to worry about is job security, financial security. I don't think that that is an anxiety that they need to carry with them at this point in time. But it's difficult times for everybody, including the health care sector. And the health care sector is going to have to be up and running as we deal with the COVID pandemic. But Veeran Shetty, Dilip and Abhay, many thanks for joining us here and taking us through a whole host of issues. Appreciate your time and your views here on CNBC TV18. With that, we'll take a quick break. Don't go anywhere. There's a lot more coming up. We're back in a moment.