Indian Healthcare system is dying
It is time to reset and reform, the current Corona crisis provides an opportunity to address inadequacies in healthcare system, and lack of safety nets for urban poor. India’s public healthcare system needs far more investment.
For any nation’s development Quality Education and Health Systems plays a significant role but unfortunately all our successive governments neglected Health Care System i.e., right from Investment in Medical Education to Health Care System to allocation of Funds.
With the launch of Ayushman Bharat — PMJAY in 2018 (world’s largest government healthcare scheme), 50 crore marginalized beneficiaries have an opportunity to get access to hospital care. Additionally, healthcare in India, particularly the hospital and MedTech space is set for growth and innovation through FDI and PE funds.
Healthcare scenario then and now?
India, a country with a centuries-old heritage of medical science, first became familiar with the modern systems of medicine in the 17th century. Though India became an independent nation in 1947 and became a Federal Republic in 1950.There have been various developments in the health sector in the post-independence era. But problems like higher population density, low socioeconomic status of a significant number of people and low literacy rate in some parts of the country, have resulted in poor health indicators. India has a rich, centuries-old heritage of medical and health sciences.
The approach of the ancient Indian medical system was one of holistic treatment. Since independence, considerable progress has been achieved in the promotion of health in India. Smallpox has been eliminated, and mortality from cholera and other related diseases has decreased. But episodes of cholera continue to recur, and the incidence of tuberculosis is not insignificant.
The situation regarding public sanitation, preventive healthcare, control of communicable diseases and health education needs to be improved. In addition to the diseases of poverty and malnutrition, non-communicable diseases related to urbanization, such as diabetes mellitus, hypertension, cardiovascular diseases, and cancer is a cause of concern.
Road traffic accidents, geriatric problems, and complications of autoimmune deficiency syndrome (AIDS) are also on the increase. Though hospitals, dispensaries, public health centers and other medical facilities are present, they are not sufficient to cater to the growing needs of India’s substantial population. Rural access to quality medical service must be improved. The inadequate workforce of doctors in public sector hospitals is also a concern for health authorities.
Furthermore, the infrastructure required in the hospitals, like medicine & infrastructure are not adequate to serve the population. Compounding the problem, government spending on healthcare services is not up to the World Health Organization (WHO) norms of gross domestic product in healthcare.
Though the public sector is not expanding its healthcare services, private, co-operative, and other non-profit organizations have started hospitals and are providing medical services to the public. Moreover, the Government of India is taking other steps to improve healthcare. For example, the Government has, from time to time, appointed various committees to address the pervasive problems in the healthcare sector. In addition, it has demonstrated a strong commitment to population control, including the implementation of family planning programs geared towards controlling the population. But nothing has changed, everything remained to be same and as time passes by, we are growing very vast in terms of population.
Current India’s healthcare scenario seems to be at the crossroads due to huge economic burden due to NCDs, struggles to balance accessibility, affordability and quality and is unable to hike public health budgets.
The current scenario – Amidst the efforts going on, there are several challenges in the current state of healthcare in India include inadequate reach of basic healthcare services, shortage of medical personnel, quality assurance, inadequate outlay for health and most importantly insufficient impetus to research. Since the magnitude of these challenges is significant, these cannot be resolved by the government alone. The key is to get the private sector to participate, while the government continues to invest and enable. Over the past decade, healthcare services available in India have increased dramatically.
Is it due to Lack of Sociopolitical Demand for Good Health Care?
There is a general mood for economic development in India. But do economic development of a country and growth of health care industry is meant to be in alignment? As a country should not India be saving on unnecessary unregulated health care spending. With a huge population to cater and profound morbidity in the undeserved; shouldn’t India be targeting on cutting down the sickness levels thereby down regulating the spending incurred due to preventable causes of death and disability? A relatively young population is our dividend, but how are we going to benefit from it if the same population is crippled with disease, illness, and sickness and simultaneously burdened with low quality or costly healthcare?
India must strive to develop a vision to reap economic benefits of a healthy citizenry rather than focusing all public health policies on growth of health care industry. The priority of public health policies should be an alignment with the public interest. It is healthy to keep public health policies noncontaminated from the interests of health care industry.
Corruption in healthcare is not limited to the practices of the individual medical practitioners. It has a wider international and national perspective. By signaling out the professionals only, public is left out with little leverage in negotiation with dominant industry forces, while the wider malaise goes unnoticed from the public scrutiny.
Political leadership should be pragmatic enough to respond to this crisis and should not wait too long for health care to become an electoral political demand; thereby saving decades for Indian democracy.
The Right to health and advances in healthcare protection
The Indian Constitution has incorporated the responsibility of the state in ensuring basic nutrition, basic standard of living, public health, protection of workers, special provisions for disabled persons and other health standards, which were described under Articles 39, 41, 42 and 47 in the Directive Principles of state policy. Article 21 of the Constitution of India provides for the right to life and personal liberty and is a fundamental right.
Keeping in tune with the universal declaration of human rights and various other developments in the Indian healthcare sector, the judiciary has included the right to health under Article 21. In accordance with the recognition of the fundamental right to health, the Indian Government adopted a national health policy targeted “health for all” by the year 2000. Although the country could not achieve all the benchmarks by the targeted date, the Government has set a revised date of 2015, by which time it hopes to meet the millennium development goals.
The judiciary, through the process of judicial activism, has transformed the Indian health scenario. The right to health is now a fundamental right; hospitals are included under the purview of the Consumer Protection Act, ensuring timely and emergency care for patients in all hospitals (the patients can approach the Consumer Forums to redress grievances); and actions are taken against cases of negligence. The legislature has also introduced acts like the Transplantation of Human Organs Act, Prenatal Diagnostic Techniques Act, Medical Termination of Pregnancy Act, and others to improve healthcare. The media must play an important role, by bringing the problems of the healthcare sector to the attention of Government authorities.
The use of decision support systems and technology is critical to solve the issues. “When we have limited resources and limited supply of skilled caregivers, it is necessary to find ways to use technology to maximize their throughput without sacrificing on quality and outcomes. Technology can play a big part in this; it is the best way to achieve the vision of a connected healthcare ecosystem. Medical devices in hospitals. clinics, mobile care applications, wearables and sensors are all different forms of technology that are transforming this ecosystem. Along with technology, by adding an analytics layer to this, caregivers can provide a much better analysis of the condition and recommendations to the patient, On one hand, we face an ever-increasing need for quality and accessible healthcare, the double burden of communicable and non-communicable diseases (NCDs), inadequate healthcare infrastructure and lack of skilled resources that add to the burden of providing quality care to the patient; on the other, our doctors are globally recognized, and India is the chosen destination for international patients with often incurable disease conditions, who find the right medical solutions in India.
The biggest challenge the healthcare sector is facing currently is the shortage of skilled medical workforce. He informed, “There is one government doctor for every 10,189 people in India, whereas the WHO recommendation is 1:1000. Although, six states in India like Delhi, Kerala, Karnataka, Tamil Nadu, Punjab and Goa have more doctors than the WHO norm, it is a highly imbalanced picture and most of them are unwilling to move to Bihar or Uttar Pradesh (UP), the states that suffer from an acute shortage of doctors. There needs to be a system where we can focus on skilling and upgrading medical workforce skills in the needed geographies. Here, the private sector can play a vital role in the skill development of doctors, nurses, and health workers.
Insurance in the Healthcare Sector
Most developed countries have a widespread insurance network in the healthcare sector. But, in India, the insurance industry is only now picking up. The percentage of the Indian population having health insurance policies is very low, and there are very few companies offering insurance in the healthcare sector. Nonetheless, it is expected that insurance will play a major role in the Indian healthcare system soon.
Availability of Information and Impact of Information Technology in Healthcare
Consolidated data on the healthcare service is not available, and the mechanism of assimilation of data on the national level is not efficient. However, there are islands of excellence in some of the national institutes and a few other centers. The developments of information technology, such as a computerized hospital information system, are available in some of the centers. In addition, the Indian Space Research Organization (ISRO) has embarked on a telemedicine project, which has potential to provide specialist service to remote areas.
The current state of healthcare in India is a triple A crisis of access, affordability, and apathy. Given that we are not a developed nation, access to healthcare is a major issue in India. We must attract the best talent into the profession, who are apprehensive because violence against healthcare professionals is creating ‘fear.’ This, and lack of availability of medicines and healthcare services, aggravates the access problem. In terms of affordability, healthcare is a calamity that throws an afflicted family into the jaws of poverty. Government spending on public health is just one per cent of GDP in India. How to spend scarce tax rupees on healthcare must be considered carefully. World over, the trend is towards healthcare management, focusing on patient education and prevention.
The current biggest challenge India’s public and private healthcare sector is facing is revolutionizing medical education. A student pursuing medicine must study for over five years to get an MBBS degree, then another three years for a postgraduate and a further three years for a super-specialty like cardiology, neurosurgery, etc. This alone does not suffice, and they must spend few years to gain experience. To add to this, most medical education in the country is controlled by private medical colleges charging over a crore rupee for an MBBS seat or more than Rs 2- 3 crores for post-graduate seats. We must ensure that medical education is affordable. Apart from that, the government must also allow private hospitals to train young doctors in super-specialties.
Insurance providers, be it government or private players, insurance companies, are taking steps to fix prices of healthcare services, which are putting margin pressure on private healthcare providers. These providers are still to realign their cost structures to effectively respond to these challenges.
Policymaking: A cause of concern?
Policymaking is certainly one of the most important aspects for providing effective health services. The problem in India is fundamentally of supply than demand. Policymaking must largely focus on encouraging capacity creation in the supply side. Price will be an outcome of the balance between demand and supply. While price controls, especially on the essentials may be required, the key to solving this from a long term is to focus on creating supply. The supply problem is not just restricted to capacity, but also to access. So, both need to be addressed.
Certain industry practices in the healthcare value chain had inflated the prices to levels which were a cause of serious concern from a patient’s affordability perspective. Hence, regulatory price controls were introduced, which in turn impacted profit margins of the private healthcare sector. While the need is appreciated, the controls should not lead to healthcare providers becoming financially distressed, especially when hospital infrastructural inadequacy is a serious issue in itself.
The best outcomes can be achieved if any policy is framed through a consultative approach with inputs from all stakeholders. It is always viable to have a roadmap for a comprehensive policy formulation in consultation with the hospital sector and other stakeholders.
Strengthening public health, the Government of India has introduced several programs to provide better care to its citizens. Ayushman Bharat – PMJAY, the non-communicable diseases program, the communicable diseases programs on tuberculosis (TB), malaria, HIV and the National Tobacco Control Program, the Pulse Polio campaign, or the national immunization program, have done commendable work. However, more needs to be done.
Healthcare and social security in general can no longer be the responsibility of a single department or ministry. Clean water and air, without which good health is not possible, depend on cropping practices, industrial regulation, pollution control, environmental protection, and law enforcement. It is not a single policy, but interconnected, multi-pronged thinking that is needed. In addition, India is now amid a significant economic slowdown, and investments have slowed down considerably. In such a scenario, policies about cost-cutting cannot be the only answer. If hospitals are to survive, the government must encourage medical tourism in a big way. Policies pertaining to social security – that include care of expectant mothers and children, unemployment allowance, disability payments, old age security, skills training and re-skilling, housing, and healthcare, are all linked.
The industry and government must collaborate to come up with efficacious solutions. To achieve sizeable gains, it is important for the government and industry to develop partnerships with a focus on improving coverage and providing access to quality healthcare services to the people. The move to open one medical college for every three parliamentary constituencies will help in addressing the challenges related to availability of healthcare professionals in hospitals, improve access to healthcare and bridge the demand-supply gap.
We need the government and the pharma companies to work together and arrive at a model that resolves the commercial and the social objective.
As the population ages and more people begin to need medical and social care, this dual problem is poised to assume mammoth proportions in the next 20 years, unless we take significant measures to address it now with bold measures in policy and implementation.
Digital tools India is currently experiencing a digital revolution. Healthcare too is witnessing a digital transformation. Leveraging digital technologies can certainly strengthen healthcare delivery in India, opine these experts. “Digital technologies are driving greater efficiency in healthcare delivery. Electronic Medical Record (EMR), the digital version of physical medical record, for instance, is playing a crucial role in optimizing patient care by ensuring continuity and aiding information sharing across caregivers (hospital, diagnostic lab, pharmacy, etc.). It replicates existing processes digitally with different degrees of automation, reasonable process optimization and operational management information system (MIS), which otherwise is labor-intensive and prone to human error.
The significance of telemedicine which is of immense benefit to patients in remote locations. It offers convenience, it helps them to gain access to doctors without physical travel. This aid better management of chronic diseases and consistent post-operative monitoring. Wearable technology is aiding seamless and accurate health monitoring. For example, the advent of wearable devices supported by mobile technology, can now allow a doctor to monitor a patient’s vitals remotely. This technology has in-built patient monitoring devices which provide information on heart rhythm, blood pressure, breathing patterns and blood glucose level.
Technology is transforming the healthcare sector in India. It can improve our long-term health by tackling several issues. It has already helped us to develop improved medicines and drug dosage combinations, screen patients better, detect diseases early, perform complex surgical interventions, etc. AI is a major technological breakthrough for the medical space. It allows for the creation of a personalized environment for both patients as well as healthcare providers.
Mentioning further innovations, he said that big data is another area which will allow for preventive care. “It will also allow for analytical solutions which will give insight into treatment viability, drug utilization and self-care programs, specific to chronic conditions. Blockchain will bring healthcare efficiencies by providing transparency in process, eliminating intermediaries wherever possible, providing a guard against counterfeit drugs, and reducing unnecessary healthcare costs.
Getting a little deeper into technology rapid developments in mobile technologies, cloud computing, digital imaging, machine learning and 3-D printing have paved the way for breakthroughs in the development and adoption of healthcare technologies – from telemedicine to nanotechnology, lab-grown 3-D organs to internet of things and electronic health records to AI. Besides, the use of data to build India-centric research (most of the research in the medical field is largely based on the Caucasian samples) is possible only through digitalization.”
The importance of digital tools in healthcare is significant. Apart from clinical decision support tools, digital tools can make clinical expertise available either remotely or through expertise embedded in medical equipment. The examples include digital pathology, tele-radiology, point of care diagnostic devices, tele-consultation, etc. The second issue is to keep millions of frontline health workers updated about the latest knowledge and skills, where e-learning academies and virtual classrooms can be of great help. Thirdly, these can help in enhancing the quality and effectiveness of care being delivered on the ground by paramedic staff like Accredited Social Health Activist (ASHA) workers using appropriate apps on e-pads/mobile phones.”
Ayushman Bharat and partnerships Public-private partnership can be one of the solutions to resolve the problems that Indian healthcare faces. The private-public partnership is the only way to solve India’s healthcare problem. The starting point for this, as in any partnership, must be mutual trust and a recognition that the solution must be a win-win for both.
The World Health Organization (WHO) estimates that one billion people lack access to basic care, and a further 100 million are pushed into poverty trying to access it. There is a strong need for social entrepreneurship in healthcare. For success in healthcare, we need to turn the problem around from treatment to prevention. To bring a change, work must be done at the community level. We need to look beyond the narrow roles of the state, business, and patients to draw on our collective strength; social entrepreneurship may just hold the key.
The biggest service that can be purchased from private hospitals is to train young doctors and paramedical staff. This is a simple solution to the crisis of poor doctor-patient ratio in India. It would open up thousands of medical seats at no extra cost to the government, by allowing large private hospitals to train and award graduate and postgraduate degrees.
There is a unique opportunity for India to skip a full generation and transform healthcare and healthcare delivery using digital technology. Healthcare can learn so many things from new-age businesses and transform India.
Corporatization of public hospitals (creation of legal structures such as trust, state enterprise, etc. which can separate these from government administration) — many such transitions have been carried out in countries like the UK, Sweden, Singapore — which could lead to better efficiency, quality and patient satisfaction.
In an overarching sense, I see virtual reality, big data, Internet of things (IoT), telehealth, robotics and genomics as areas which will define healthcare and exponentially impact its delivery to the masses.
India, the land of Ayurveda, has a wide variety of special treatments to offer. In addition, there are hospitals practicing modern medicine that provide quality service at an affordable cost. When compared to the expense of medical treatment in Western countries, India’s facilities for treatment, natural beauty and tourist destinations across the country will make it a popular destination for people of all nationalities seeking healthcare.
In the year 2006, the quality council of India, through the National Accreditation Board for Hospitals (NABH) has come out with hospital standards that are applicable to Indian hospitals. The likelihood of an insurance boom in the healthcare sector and the potential for health tourism are important reasons for accrediting the hospitals. Therefore, accreditation and quality health service will be the main agenda of hospitals in the years to come.
India has made striking progress in health standards in the post-independence era. Still, many feel that the budgetary resources for the health sector should be increased. International developments in information technology need to be utilized at the national level in an attempt for health data documentation. The sustained efforts to control the country’s population and the political will to march towards the millennium development goals in health will help India to make a significant impact in the international health scene. Change is an inevitable fact of life. With the hope that the new decade will bring in the much-needed positive change in Indian healthcare, the government, industry leaders, healthcare experts, doctors and other stakeholders have set their goals for the future. The only question that arises is that how soon will these efforts bear fruit?
(The author is a Public Policy Analyst, Independent Researcher, IT Professional. He is a regular contributor to Kashmir Vision)