MissionICU and 10BedICU: Rapidly Strengthening ICU Capacity in Towns and Rural Areas

Introduction

The second wave of COVID-19 cases in India in May-June 2021 overwhelmed the country’s health care infrastructure and left residents scrambling for oxygen and beds. Larger metropolitan areas (“metros”) bolstered their capacity by establishing jumbo COVID-19 centers, but such centers were missing in towns and rural areas. Despite bearing half of the COVID-19 burden during the second wave, the smaller cities, towns, and rural districts of India were lacking crucial intensive care unit (ICU) capacity. Whereas most higher-income countries have more than ten ICU beds per 100,000 people, India has only 2.5 ICU beds per 100,000 people and about 80 percent of these beds are in metros.¹

Two initiatives, MissionICU and 10BedICU, were established to help address the ICU capacity shortage in smaller cities, towns, and rural districts throughout India. These initiatives have proven to be promising practices for quickly strengthening ICU health care capacity and saving lives.

The 10BedICU initiative aims to support existing government district and taluka (subdistrict) hospitals by adding ten ICU beds. Increasing capacity in these hospitals not only helps COVID-19 hospitalizations in the short term but also strengthens the capacity of smaller towns to manage future health crises.

Between May and October 2021, 10BedICU set up ICUs in Telangana (40 hospitals), Andhra Pradesh (36 hospitals), Karnataka (40 hospitals), and in four northeast states: Manipur, Nagaland, Sikkim, and Meghalaya (118 hospitals).² MissionICU has set up ICUs in four district hospitals in Karnataka, with ten more centers in the pipeline.³ Each ICU setup costs approximately 4 million Indian rupees (US$50,000).

Background: 10BedICU is a partnership of five nongovernmental organizations: eGov Foundation, Nirmaan Organization, Karuna Trust, CoronaSafe, and GiveIndia Foundation. Its first ICU was launched in June 2021.⁴ MissionICU, a social collaborative initiative that aims to strengthen ICU capacity in smaller cities, towns, and rural areas across the country, was started in May 2021.

How can you replicate or adapt this promising practice?

Standardize to rapidly scale

The initiatives include a standardized package of ten ICU beds and related ICU equipment, which are then delivered to government hospitals. Standardizing the ICU kits helped them more easily raise funds, seek tenders, and negotiate with equipment vendors to plan the logistics and scale the initiative quickly.

Offer affordable and bundled packages

Providing ten ICU beds and related equipment was cost-effective at about 4 million Indian rupees (approximately US$50,000) per hospital. Additionally, purchasing equipment in bulk enabled both project teams to negotiate annual maintenance contracts in addition to installation of equipment and training of staff.

Build a social franchise model

As of November 2021, MissionICU was in the process of building a social franchise model, which other organizations can use to implement their own ten-bed ICU model. MissionICU is developing a blueprint of the model for interested organizations.

Partner with multiple stakeholders

Working with partners who are experts in technology, public health, field implementation, strategy, and finances helped the two initiatives achieve their targets and stay on course. For example, 10BedICU’s strategic partners include the eGov Foundation, Nirmaan Organization (implementation), Coronosafe (technology ), and Karuna Trust (public health). MissionICU’s partners include CHD Group (public health and implementation) and PrimedeQ (implementation and operations). Partners who fund and support these initiatives include the Crypto Relief Fund, GiveIndia, HDFC Bank, S&P Global, Kantar Group, and other foundations and associations including the Wadhwani Foundation, the US Agency for International Development’s SAMRIDH financing initiative, Hyderabad Software Enterprises Association, Arogya World, as well as philanthropists and individual donors.

What are the lessons learned from this bright spot?

The focus of 10BedICU and MissionICU is setting up ICU infrastructure to strengthen and improve government health systems in smaller cities, towns, and rural areas in India. The initiatives have enabled health systems in smaller areas to receive donor funding they would not typically have access to, which has in turn strengthened their ICU capacity and ability to manage health crises. 10BedICU has a four-pronged approach to manage shortages related to infrastructure, personnel, training, and appropriate COVID-19 management capacity. The four prongs are as follows:

Set up ten ICU beds in rural districts
Train existing health staff on COVID-19 protocols
Set up a telemedicine program with the help of specialists from the United States, United Kingdom, and urban areas of India to advise local medical professionals
Provide a technology platform called CoronaSafe for comprehensive COVID-19 management

The ICU equipment provided by 10BedICU includes 2 ventilators, 5 monitors, 5 suction apparatuses, 2 infusion pumps, 2 ICU trolley beds, 3 ICU beds with plastic bins, 25 oxygen cylinders, 2 oxygen concentrator, and 4 laptops with CoronaSafe and DoctorConnect programs. This equipment augments the ICU capacity to optimally manage ten ICU beds in a given setting.

How was the promising practice implemented?

As of October 2021, around 250 government hospitals in towns and rural areas have additional ICU capacity, thanks to 10BedICU and MissionICU. The initiatives have equipped the rural areas to meet India’s growing health care needs and better manage future pandemics and crises.

Gadag Institute of Medical Sciences installation event

Assess and identify recipients

For both initiatives, nonprofit partners provide financial support and delivery of the ICU-related equipment, while the government hospitals or administration provide space, utilities, internet connectivity, and staff.

For MissionICU, the process of selection begins with a questionnaire about existing ICU capacity, permanent and contractual staff, and agreement to sharing data. Based on their intelligence reports, questionnaire, and hospital’s own willingness, hospitals are selected to receive the ten-bed ICU package. Once the district surgeon receives the equipment, they send a letter acknowledging receipt and the equipment is recorded as an asset with the district hospital.

For 10BedICU, a project management unit was created with senior state officials including the additional chief secretary of the Health and Family Welfare Department, the principal secretary of the Rural Development and Panchayat Raj Department, the head of the government’s COVID-19 task force, and members of 10BedICU, including its nonprofit partners—eGov Foundation, CoronaSafe, Nirmaan Organization, and GiveIndia. District collectors (administrative head of the district) then design, review, and oversee the implementation of the project.

In both cases, the hospitals sign a memorandum of understanding with the nonprofit partners to begin the process of receiving shipments. The initiatives have determined the requirements needed for the ICUs to be successful, as discussed in more detail below.

District Hospital, Tumkur installation

Prepare for delivery

Once the hospitals are selected to receive the shipments, they need to prepare to receive the equipment. This preparation process involves establishing oxygen supply lines, installing air conditioners, and completing wiring and LAN connectivity, which requires assistance from the public works department and can take up to three weeks.

Ensure sufficient human resources

District hospitals need to have an adequate number of existing specialists and nurses, through either permanent or contractual positions, before they receive additional equipment. This ensures that ICUs are fully functional and used appropriately in a sustained manner.

Leverage technology for monitoring and management

ICU beds provided by 10BedICU are connected to a COVID-19 management technology platform called CoronaSafe that provides real-time analytics of beds, ICUs, and ventilators. This platform helps with monitoring and effective inventory management including the utilization and downtime of equipment.

Use telemedicine to address staff shortages

Considering the acute shortage of trained specialists in rural areas, 10BedICU provides a “Doctor Connect” module that enables global expert doctors to assist ICU bed patients using a telemedicine platform. It has one specialist attached to each ten-bed ICU setup and provides expertise with the help of video communication and personal health records.

Provide support for equipment maintenance

District hospitals that receive equipment also receive support for maintenance of the equipment during the initial years. MissionICU provides one year of support and 10BedICU provides three years of support. After this initial period, hospitals are responsible for maintaining the equipment themselves.

District Hospital, Yadgir

Voices from the field

Strong collaboration with partners, specific needs identification and end-to-end support from 10BedICU and MissionICU received great praise from all stakeholders involved.

We have got tight checklists on how to go about it [getting the site ready for the delivery]. It is just not the money, it’s the sort of hand holding that we’re doing locally is really what governments need. Often, they’re not able to spend the money because they don’t have the capacity to think it through and work enough detail in order to implement these things successfully. —Srikanth Nadamuni, Co-Founder of 10BedICU, Founding Chief Technical Officer of Aadhaar

We received three ventilators and ICU-related equipment from [MissionICU]; they sent it during the peak of the second wave when we needed them the most. We used them for setting up both a new pediatric ICU and a HDU [high-dependency unit], planning for the third wave. We already had contract and permanent staff appointed for the 35 ICU bed facility at the hospital so we didn’t need any additional training. —Dr. Shankar D, Medical Officer, Antiretroviral Treatment Center, District Hospital, Tumkur, Karnataka

Voices from the funders

Adding in ICU beds at the district hospitals, instead of opening up new hospitals, did make sense and that would be a steppingstone to start building upon existing government infrastructure. On the day of project launch in Telangana, there were already two patients admitted in the ICU beds even before formal inauguration. That’s when it hit us very hard about the dire shortage of beds on the ground. —Punit Agarwal, Founder of Zubi, CEO of CryptoRelief Fund

What I liked about MissionICU was that it was the need of the hour. [They were not] building hospitals but augmenting infrastructure of hospitals to be ICU ready in Tier 2 [smaller] cities so that they are not overwhelmed when COVID-19 wave reaches them. This is a sustainable improvement of India’s health care system. —Nalini Saligram, Founder and CEO of Arogya World

Supplementary material

MissionICU and 10BedICU - Rapidly Strengthening ICU Capacity in Towns and Rural Areas.pdf

Sources

Balachandar, G. On a mission to take ‘drop-in ICUs’ to every taluk. The Hindu BusinessLine. November 13, 2020. Accessed October 7, 2021. https://www.thehindubusinessline.com/news/on-a-mission-to-take-drop-in-icus-to-every-taluk/article33087216.ece
10BedICU. Our team. Accessed October 8, 2021. https://10bedicu.org/our-team
MissionICU. Accessed October 8, 2021. https://missionicu.org
@srikanth_tweet. Launched 1st 10-Bed-ICU in Telangana with @KTRTRS and @vkhosla to combat @Covid19 in rural India, Vinod announces funding for @10BedICU in 100 more districts. Currently Working in 4 states, 8 more in the pipeline: http://10BedICU.org7. June 6, 2021. Accessed November 15, 2021. https://twitter.com/srikanth_tweet/status/1401728355683037186