India has a large and diverse healthcare system that suits the cultural diversity of the community[5]. The healthcare system in India was initially built to ensure that all citizens have access to essential healthcare services regardless of their socioeconomic status[19]. However, the ambitious healthcare system plans were not associated with considerable funds from the governmental agencies. In 2015, India spent only 1.2% of its gross domestic product (GDP) on health, considered among the lowest in the world[20]. The inadequacy of government healthcare services has resulted in the simultaneous evolution of the private health sector[21]. Subsequently, India has one of the highest proportions of household out-of-pocket expenditures on health globally, estimated at 71.1% in 2008-2009[22]. In addition, India has the lowest doctor-patient ratios as it has one doctor for 1000 and a specialist for every 1445 people[23]. The low healthcare expenditure in India had a severe negative impact on health status even before the COVID-19 pandemic. The pandemic further stretched the fragile nonimmune Indian healthcare system, leading to a collapse in providing healthcare services in order to contain COVID-19.

Among its 1.3 billion citizens, NCDs are responsible for 5.78 million (60%) of all deaths in India each year. The significant NCD-related deaths are usually attributed to cardiovascular disease, cancer and diabetes[24]. The rising NCD trend is a common phenomenon seen in developing countries where rapid urbanization leads to an overall economic improvement and has considerable adverse effects on public health[25]. The Indian health system has adopted multiple changes aiming to bring down NCD-related mortality by < 25% by 2025[26]. Although some progress has been achieved in decreasing tobacco and alcohol consumption, an increasing trend was found for overweight and obesity among Indian adults aged 15-49 years[24]. Reddy and Kar[26] have demonstrated that the Indian Government’s efforts were insufficient to achieve its ambitious targets by 2025, even before the pandemic.

Since the start of the epidemiological transition in 1970, there have been significant changes in the pattern of different diseases across every state in India[27]. Omran’s theory[28,29] describes the epidemiological transition as a shift in the causes of morbidity and mortality, primarily from infectious diseases to NCDs. However, the situation was different in India, where the burden of NCDs has been added to the burden of infectious disease, resulting in a double burden on the undeveloped Indian healthcare system[27,30]. In India, the epidemiological transition has led to the development of a new theory based on the concept of the double burden of both infectious diseases and NCDs[31]. The burden of communicable diseases has declined from 47.7% to only 22.1% between 1970 to the mid-1990s[31].

Even after 40 years from the start of the epidemiological transition in 2011, infectious diseases still pose a challenge to the Indian health system and account for about 30% of the disease burden[32]. It was estimated that an Indian citizen had a 15 times greater burden of infectious diseases than United Kingdom citizens in 2004 and that about 30% of the disease burden in India is attributable to infections[32]. The lack of strong staple public healthcare infrastructure has contributed largely to stagnation of the infectious disease burden in addition to the burden of NCDs[30,32]. For instance, in 2009, India recorded about 2 million new cases of TB, which is considered one of the highest incidences globally[32]. After 10 years in 2019, India reported about 2.9 million new cases of TB, contributing to about 27% of all TB cases worldwide[33]. However, India started its TB control program early, in 1960, but failed to significantly reduce the incidence of new TB cases compared to other countries with similar epidemiological transitions[34,35]. Concerns have been raised about the spread of TB and NCDs, specifically, diabetes mellitus, which are associated with a more fulminant course of TB[36,37].

Besides TB, multiple endemic infections affect Indian cities and states, such as cutaneous anthrax, dengue fever, malaria, cholera and viral hepatitis (A and B)[38-43]. Some of these infections are substantially preventable by vaccines[44]. Unfortunately, India contributes to about 10% of 20 million unimmunized and partially immunized populations[45]. Additionally, India is considered to have one of the largest rates of endemic hepatitis B, with the second largest burden of chronic hepatitis B, with > 50 million cases[46]. Despite being integrated into the Indian National Immunization Program in 2011, about 23.2% of children aged 5–8 years were vaccinated against hepatitis B virus[47]. Different causes have been proposed behind the low vaccination coverage of hepatitis in India; for instance, major causes are related to the poor management of the available health resources such as poor record-keeping, improper management of vaccine stocks and lack of inventory control, lack of staff training, and use of multidose vials. Strikingly, healthcare workers have been reported to be reluctant to open a vial of the vaccine when there are a few children to be vaccinated for fear of wastage[48]. It is well noted that even before the COVID-19 pandemic, India’s healthcare system was strained between the pre-existing communicable disease challenges and the evolving NCD pattern created by the epidemiological transition. All of the above challenges are further aggravated by the limited Government funds allocated to developing the healthcare system (Figure 2).

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Figure 2 Challenges faced by healthcare system during coronavirus disease 2019 pandemic. COVID-19: Coronavirus disease 2019; GDP: Gross domestic product; NCDs: Non-communicable diseases; IMR: Infant mortality rate; MMR: Maternal mortality ratio.

The number of people infected with COVID-19 has exceeded 9 million since the report of the first cases in the state of Kerala on January 30, 2020[1,6]. Following this, the country has witnessed a drastic increase in the total number of reported cases. The recovery rate across India was 80.83% as of September 22, 2020, with a case fatality rate of 2.82% as of June 1, 2020[49]. The development of the pandemic has primarily affected the rapidly developing Indian economy with shrinkage of the GDP by about 23.9% in April-June 2020[50]. Today, Indian citizens continue to be frightened into compliance and are afraid to restart their lives normally. Although many states of India have flattened their COVID-19 infection curve, authorities across the nation are now in fear from the onset of other subsequent waves of the COVID-19 pandemic secondary to a decreased commitment of health directives of taking precautionary measures, i.e., social distancing and wearing face masks. Government authorities have advised citizens to take precautionary measures like social distancing and wearing masks during public gatherings. Furthermore, a few states, such as Maharashtra, Rajasthan and Gujarat, have introduced new restrictions such as travel restrictions and night curfew to battle the subsequent waves of the COVID-19 pandemic[50].

In India, besides the chronic shortage of healthcare workers, there were significant deficiencies in different domains of healthcare services and their logistic determinants[51]. For instance, healthcare facilities have severe deficiencies in infection control measures, i.e., advance infection prevention and control facilities to contain infected patients and prevent the spread of COVID-19. In 2010, the Indian Government adopted national guidelines on airborne infection control in healthcare facilities with a special focus on preventing TB transmission[52]. Five years later, a baseline survey of healthcare facilities has demonstrated poor adherence to infection control measures aimed to control airborne infection[53]. Multiple studies have demonstrated several loopholes in the infection control policy, including insufficient training of staff, unavailability of protective masks, poor compliance to personal protective practices by health workers, i.e., proper use and disposal of personal protective equipment (PPE) and other control measures, inadequate disinfection, and sterilization of equipment, lack of health workers surveillance, lack of counseling of cough etiquette and sputum disposal at registration of hospitals[54-56].

In 2020, Indian health authorities recently updated the comprehensive national guidelines for infection control[51]. However, infection control measures across different PHC centers in Indian districts were grossly deficient, especially related to airborne infection[15]. The shortage was limited to the infection control measures, but it further extended to the PPE intended to protect the workforce from infection during the COVID-19 pandemic. It is reported that there is a persistent dearth of PPE in two private hospitals in Mumbai[57]. Reports from different areas across India have reported that doctors treat patients suspected of severe acute respiratory syndrome coronavirus 2 infection without masks or with less-protective surgical masks instead of recommended NK95 masks for healthcare providers[58]. Unfortunately, the shortage of PPE and high demands have forced healthcare workers to reuse or extend the use of PPE, which increases their risk of COVID-19[59]. The above behavior, despite being expected, highlights a lack of proper knowledge and training regarding infection control measures, usage of PPE, and their proper disposal. In fact, it is one of the rights of healthcare workers to be adequately trained before exposure to COVID-19 patients[60]. The lack of essential training of healthcare workers has been reported in several South Asian countries, including India[61]. Multiple studies have highlighted suboptimal knowledge and practice regarding infection control measures across Indian health workers[62,63]. Raj et al[54] have reported that only less than half of the healthcare workers of Kerala, India, were trained on proper infection control practices.

The growing distribution of the pandemic across different countries has delayed or even stopped the basic childhood vaccination programs as a response to the lockdown or the stretching of the healthcare resources as a response to the COVID-19 pandemic[64]. The World Health Organization (WHO) has reported that > 80 million children did not receive routine vaccination globally[65]. This may have serious long-term consequences even more than COVID-19 itself. For instance, the evolution of the Ebola outbreak in Africa resulted in halting multiple essential healthcare services, which increased mortality related to several other infections, including TB, human immunodeficiency virus, and measles which have exceeded the mortality rate from Ebola[66].

In India, the evolution of the pandemic has initially enforced complete stoppage of the whole childhood vaccination programs secondary to the major lockdown. It was estimated that about 27 million children missed diphtheria tetanus pertussis, resulting in a 40% increase in mortality in the next year. It has also been estimated that there is an expected 49000 child deaths and 2300 maternal deaths within a month if the PHC services continue to be disrupted[67,68]. As a response, the Indian Government has approved the continuation of the vaccination services and consider it an essential health service[69]. The resumption of the immunization activities was based on the WHO guidelines to minimize both morbidity and mortality from other diseases[70,71].

Maternal healthcare services have also been severely affected by the development of the pandemic. Globally, healthcare services have restricted pregnant women’s access to healthcare facilities for fear of virus transmission and the unknown adverse effects on the newborn, considering the Zika virus in the background[72,73]. The Health and Family Welfare Ministry has declared pregnant women as high risk during the COVID-19 pandemic and provides guidelines to provide essential maternal healthcare services to pregnant women, including the suspected and confirmed cases of COVID-19[74]. Goyal et al[75] have demonstrated a 45.1% decline in deliveries during the pandemic at their center. They have also noticed a surge in the number of high-risk pregnancies to about 7.2%. Additionally, more than one-third of women had no or inadequate prenatal visits, with more than half of them mentioning the lockdown as a cause of inadequacy of antenatal care.

Since reporting the first case of COVID-19, patients with chronic disease have had significant difficulties accessing their routine healthcare services worldwide[76]. The presence of chronic conditions like chronic kidney disease, cardiovascular disease, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and malignancy in a patient with COVID-19 has been tied to poorer outcome with about 10-fold higher risk than those without associated comorbidity[77,78]. WHO has reported that half of 163 countries have attempted partial or complete disruption of healthcare services for hypertension, diabetes mellitus, and related complications during the pandemic. Additionally, one-third of the countries have reported disruption of healthcare services designated for cardiovascular emergencies[79].

Low- and middle-income countries have sustained considerable difficulty in assuring access to healthcare services to patients with chronic conditions compared with western countries[80]. Pati et al[81] conducted a community-based study in Odisha, India, and found that 43% of the patients with comorbid conditions have reported difficulty in accessing healthcare services. They have also reported that the most challenging problem was the physician consultation, accounting for 43% of cases. Another telephone-based survey targeting more than 1000 chronic patients reported that > 80% of the participants found it challenging to access healthcare services, and 17% of the participants found it difficult to obtain their medications. The same study also reported that > 50% of the participants reported a loss of income, and 38% had completely lost their jobs[82]. These clear negative impacts have forced health authorities to search for more cost-effective approaches to continue healthcare services to those patients with chronic medical conditions.

Telemedicine is defined by the WHO as the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research, and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities[83]. Before the COVID-19 pandemic, India had a few worthy examples of telemedicine models, including mammography services at Sri Ganga Ram Hospital, Delhi, and oncology at Regional Cancer Center, Trivandrum[84,85]. During the COVID-19 pandemic, the contribution of telemedicine in healthcare management has been highlighted. Kumar et al[86] reported that 71.43% of the orthopedic patients were managed without needing any physical visits to the outpatient clinics. Additionally, they have reported that 92% of the patients were satisfied with the telemedicine intervention.

The catastrophic health expenditure of < 2% of GDP in India must be increased at least to meet the expenditures of the surrounding developing Asian countries[87]. The COVID-19 pandemic has indicated that dependence on the private healthcare sector, assuming that an increase in the overall income of the individuals can cover their health expenditures, cannot be a good approach to healthcare management[88]. India also needs to establish a national stock level of PPE and other essential medical supplies like ventilators together with an efficient network to monitor and deliver upon need[89]. Learning from other Asian neighbors, both Taiwan and Singapore have established a similar network of PPE management which proved to be critical and efficient in the PPE management during the pandemic[90,91].

Establishing national manufacturing units is also essential to maintain an adequate supply to the Indian hospitals and other healthcare facilities even at times of global catastrophes. The enhancement of local manufacturing on a mass scale should be essentially accompanied by maintaining the ban of PPE exportation[89,92]. Together with providing adequate equipment to fight the pandemic, there is an impending need to enhance and maintain the training of healthcare workers regarding critical topics like infection control practices[93]. Diwan et al[94] have reported that attending training sessions have significantly impacted and improved hand hygiene among healthcare workers in rural India. In adjacent countries/territory like Singapore, Japan and Hong Kong, a high level of readiness of healthcare workers has played a critical role in early controlling the pandemic[95].

Besides empowering the healthcare system, it is also essential to engage the healthcare professionals in decision-making to avoid collateral, sometimes fatal, damage of halting essential services like vaccination and maternal healthcare services even for a short period. Establishing and empowering telemedicine is another crucial lesson that should be considered in the future. Integration of telemedicine even after the pandemic should be encouraged and continue as it has proved to be effective in the diagnosis, management of chronic disease, and guiding the treatment for different medical conditions in a cost-effective way[96,97].

RCA was used in this manuscript to improve the results and highlights[98].

India was one of the countries worst hit by the devastating effects of the coronavirus disease 2019 (COVID-19) pandemic. The healthcare system was unable to manage the situation.

The underperformed healthcare system during the pandemic exposed the crisis.

To identify the challenges faced by the Indian healthcare system during the pandemic.

The review was conducted using a literature search from the database of PubMed, Web of Science, EMBASE, Scopus, etc. The main focus was on the Indian healthcare system and the impact of a pandemic.

The Indian healthcare system was already under pressure before the pandemic. The overburden of patients and essential health services were not handled efficiently. Many healthcare facilities were lacking the basic standards of patient care. The vaccination and chronic disease services were hampered due to the shifting of focus to COVID-19.

Universal Health Coverage should be provided to each person. Increase in percentage expenditure of gross domestic product for the health sector, escalate infrastructure development, and increment of skilled manpower required.

To meet the incremental demand in health care services during and after the pandemic, India needs to invest more in this sector with a goal of Universal Health Coverage.