Management Perspectives

There are many problems with our healthcare system—the crowds at the iconic AIIMS as well as major, private hospitals, mortally sick patients being turned away either for want of money or due to shortage of beds, babies delivered outside hospital doors, fake medicines, unnecessary diagnostic tests and surgeries, rampant kickbacks—the list seems endless. People continue to suffer, many mortgage their houses to pay for treatment, others just die as they are unable to afford the huge cost of treatment.

Putting in place a universal healthcare system for all is perhaps not feasible for the government—resources required would be humongous, and the private sector can barely take care of their own people. Even the reach of their CSR funds is limited to a few ‘memorial hospitals and research institutes’ that manage to corner cheap, prime land from the government, on the express condition of providing certain number of ‘free beds’ to the poor, but more often than not these are appropriated for extending favours. The situation is ironic- India has the best of doctors. They are as good as, if not better than, those in advanced economies. There is a culture of empathy and caring for the needy; our new-age, private sector hospitals are equipped with the latest machines and robots. Yet, we see so much suffering and misery all around! Even the so called ‘upper middle class’ is unable to cope with medical costs when someone in the family needs to be hospitalised. Perhaps, the only explanation is that the number of hospital beds and doctors is woefully inadequate for our huge population. So, let me start with this aspect.

WHO recommends ‘3 hospital beds per 1000 population’. Affluent countries like Germany and Austria have seven to eight! To meet the guideline, we need about 42 lakh hospital beds. As per the available information, in 2021, we had a total of 8.25 lakh beds—that is roughly 0.6/1000 persons. Before I proceed further, let me mention that ‘Public Health & Hospitals’ in India is a ‘state subject’ and state authorities often do not post information accurately and nor on time. Therefore, this figure of 8.25 lakh beds may not be correct. Even so we could’ve inched up to 0.8 or 1 bed/1000 population—a long way to reach the needed 42 lakh total in all government and private hospitals! Our public health system has, of course, seen upgradations, but we need much more. A remarkable scheme that deserves special mention here is ‘Ayushman Bharat,’ which is expected to provide significant succor to the poor. Our spend on healthcare has moved ever so slowly from 1.12 per cent of GDP in FY 2010 to 1.35 per cent in FY20.

A recent ET edit mentioned that Central and State governments’ budgeted expenditure on health, for FY 2023, was 2.1 per cent of GDP and the National Health Policy plans to increase it to 2.5 per cent in FY2025. Incidentally, USA spends an eye-popping 16.8 per cent of its GDP on healthcare! For the UK and Japan this figure is about 10–11 per cent. India’s 2.1 per cent in FY 2023 was the lowest amongst BRICS nations. It is also worth mentioning that the distribution of healthcare expenditure in India, between public (38 per cent ) and private (62 per cent ) is highly skewed. I think the rub lies in the fact that out of the R5.8 lakh crore total spent in 2016-17, only R1.9 lakh crore was on capital expenditure; so there was very little ‘capacity building’, i.e., the addition of new hospitals! Opening new AIIMS, initiated in 2012 (six opened that year) and accelerated in 2014 is a great idea but not many of them are functioning satisfactorily due to shortage of manpower and construction delays. An early March ’24 report talked about 108 ‘functional’ new medical colleges and another 49 being in the process. A wonderful news, reported early April mentioned ‘foundation stone laying of a 30-bed Community Health Centre (CHC) in a Haryana Village Bhora Kalan’. Now, that is exactly what we need—literally thousands of such centers all over the country. There are, of course, huge improvements on the ‘mother and child health’ front. For example, MMR (maternal mortality rate) came down from 556 per 1 lakh population in 1990 to 122 in 2014–16 and further to 103 during 2017-19. UN has set a target of bringing down MMR globally to under 70/ one lakh by 2030 as a sustainable development goal (SDG) and, happily in India, eight states have already achieved that. Schemes like Anemia Mukt Bharat and transfers through direct cash benefit (DBT) to pregnant womens’ bank accounts have helped hugely to ensure basic nutrition. Similarly, Infant Mortality Rate (IMR) which stood at a catastrophic 190/1000 live births in 1950, came down to 27.7 in 2022 and is expected to reach 5/1000 by the year 2100. On the immunisation front, a 2019-20 report, by Ministry of Health & Family Welfare, disclosed that 62 per cent of all children between the age of 12 to 23 months had been fully vaccinated in 2015-16.

Death rate in the country, which stood at 25/1000 in 1950, came down to 7.27 in 2011 and 6.71 in 2019. Sadly, 2021 saw the same spike to 9.45 due to COVID but is now coming down. Deaths due to communicable diseases have been controlled pretty well but those due to noncommunicable diseases have risen sharply, the biggest killer being cardio vascular diseases, followed by cancer, diabetes, and chronic respiratory cases. We do have an elaborate Public Healthcare System through a network of about 30,000 primary health centers, 5,600 CHCs, 1,250 sub-district hospitals, and 1,000 district hospitals with about 7.4 lakh beds available in public facilities. Then there are CGHS and ESIC hospitals. Defense and Railways have their own set ups of efficient hospitals and even a highly ranked ‘Armed Forces Medical College’. Sadly, the multi-tiered government set up it is very inefficient. Many of the PHCs often do not have doctors. There’s some sort of a mandatory ‘rural service’ tenure for all those graduating from government colleges but most manage to dodge the system. Not to put the entire blame on the young doctors, it is a fact that living conditions in the villages are just too bad to attract these bright men and women. So, the bottom line is- patients load moves on to tertiary care hospitals concentrated in big cities and metros. In a country of our size and it complexities, we need a much more robust government healthcare system at the primary and secondary levels rather than pushing everything to the overcrowded and super expensive tertiary hospitals.

We have to find means of significantly increasing the number of beds in PHCs and district hospitals and making sure that these are all well-staffed and run efficiently. We also need many more medical colleges to add thousands of doctors in the country. More colleges—especially by the government—will also ease the nefarious practice of capitation fees charged by private colleges which have mostly become moneymaking businesses. Let me quote Dr Basant Garg, additional CEO National Health Authority from what he wrote in a recent article. “Empowerment, not just treatment, defines the future of Indian Healthcare.” He goes on to add a ray of hope when he says, “ABDM (Ayushman Bharat Digital Mission) is helping India leapfrog technologically in its healthcare sector to provide a seamless, interoperable, and efficient digital healthcare infrastructure.” He feels this will make the system citizen-centric rather than disease-centric and it will empower citizens to access information related to their health, healthcare professionals, facilities, and insurance claims. He envisions that under Ayushman Bharat Health Account, citizens will have access to their health records digitally and will not have to worry about carrying their records physically. I will now turn to the importance of regular health checks which are rampantly ignored by large number of people, perhaps due to (a) non availability in smaller towns/ villages and (b) high costs, mostly not reimbursed by insurance companies. In particular, I want to talk about cancer screening tests which are now easily available, at least in the metros. There is a deep-rooted lethargy and fear with large number of Indians for getting cancer detection checks even when such tests are available free of cost. Let me mention here that ‘almost all cancers are completely treatable if detected early stage. Several cancer hospitals and NGOs have been offering basic check-ups virtually free of cost. But a vast majority do not avail of these, perhaps due to the fear of cost of treatment and the toll it will take on them and their family treatment. While this is a ground reality, one has to understand that once the disease advances- (a) treatment cost will probably become 10X (b) there is every possibility of great pain and even fatality, and (c) many hospitals offer treatment at concessional rates and also free in case of 10 per cent low income patients.

Hospitals and NGOs regularly organise ‘cancer detection camps’ in middle- and low-income colonies, fair amount of publicity is done in the area through posters or door to door information… even RWAs are roped in… and yet, response of the people is less than the optimum numbers that can be screened in a typical 8–12-hour day. All this continues to rapidly increase the number of cancer patients in the country. Incidentally, once a person is diagnosed with cancer, even after successful treatment and no reoccurrence for as long as 15–16 years no insurance company—public or private— accepts the person for medical cover. Even in case of an existing policy, the insured cannot increase the amount covered! Most heartrending is to see little kids afflicted with cancer. Recently in a short video, gone viral, someone asks a group of youngsters “which screen has changed your life?” Answers ranged from mobile phone to laptop and from TV to cinema.

However, one girl narrates how her young and fit doctor friend had succumbed to cancer and her closing words, “if only she had taken the simple cancer screening test, she would’ve been here with us,” shake up everyone in the group; she closes the conversation with “for me this screen has changed my life!” Just cervical cancer alone claimed the lives of 341,000 women globally in 2020 alone. Most of these deaths occurred in low- and lower-middle income countries due to inadequate access to cervical cancer prevention, screening, and treatment. In India, this is the second most prevalent cancer in women (14.7 per 1 lakh women) and needs urgent steps to check its frightening spread. We need a concerted drive to increase the capacity and geographical spread of screening facilities and a strong drive to sensitise the people about consequences of not going for regular basic screening tests.

Need for mindset change

The Indian mindset ignores the need for preventive care—be it for cancer or heart or other NCDs—that ultimately leads to bigger problems and the unbearable load on our very busy and very expensive tertiary care hospitals. This load can be considerably reduced if the Health & Wellness Centers (as the PHCs are now called) are tasked with prentice care through regular screenings. I will now turn to the ‘mystery & malaise’ of kickbacks and unnecessary surgeries. I can never forget an incident about 30 years ago when the son of a close friend in Punjab came back after finishing his MD in diagnostics. His parents, who were already running a successful business, added a diagnostics wing in the same premises and ordered equipment for x-ray, ultrasound, CAT scan, etc. The family scion was to start professional life in style. As the parents knew lots of doctors in town, he was hoping to get good referrals. On the very first day, as the young man was doing an ultrasound, his assistant came and whispered that a highly reputed big doctor wanted to speak with him urgently. Reluctantly, he apologised to the patient and left midway to take the call. The doctor on the other side said, “Puttar, I have sent Roshan Lal (name changed) for an ultra sound; please confirm his gallstones.” “But uncle I don’t see any stones,” responded the young chap. The doctor livid. “You have started work today, whereas, I have been in practice for 60 years; will you now teach me these things? I know he has stones in the gall bladder and needs an urgent surgery; if you can’t ‘see’ any stones, just tell him your machine is out of order and send him to another lab. And, don’t expect any more referrals from me,” said the doctor and slammed the phone! The poor kid was in tears and ran to his parents’ office. When they heard the name of his caller, they too also scared and told him, “We can’t make Doctor Sahib our enemy; we will call him in a day or two and make amends. Right now please do his bidding.” The guy was aghast, but had no choice. Soon he understood the ‘system’; there was a widely circulated list that mentioned rates for different tests, which had to be paid in cash to the referring doctors religiously every week. ‘No payment, no referrals’ was the accepted norm. So, his lab prospered while his dad kept a meticulous account, prepared small white envelopes every Sunday that his peon would go and deliver at the doctors’ homes. There were no secrets and no bashfulness in this straightforward business. I tried raising this issue in several meetings of national industry associations and chambers but was patronisingly corrected by CMDs of large chains- “You must be talking about independent labs in small towns. Such things don’t happen in large corporate outfits.” I hope and pray they were right and the malaise is confined to small places.

Do I really need this surgery?

Early in 2019, I started feeling pain in the calf behind my right knee. This was odd as I was used to walking 7–8 km daily. I sought an appointment with a doctor friend at a big hospital and was advised to get knee x-rays and an MRI of the right one. A week later, I was back in the doctor’s office with all reports. The doctor walked in, trailed by half a dozen juniors, had a good look at the reports, pointed out a ‘meniscus tear’ in the right knee, and advised ‘orthoscopic medial meniscus balancing procedure’, saying it might give me relief for anywhere between 2–3 months to a couple of years. I was told that this minor intervention is being suggested “in view of our friendship” as, with the degenerative changes, I was likely to need total knee replacement (TKR) pretty soon. I was shaken and decided to seek a second opinion. My quest took me first to another doctor friend at another big hospital who didn’t think a surgery was needed and advised an ultrasound of the right calf and also some digital x-rays of the spine + some tablets. Thoroughly confused, I met yet another doctor in the same hospital, who noticed ‘degenerative changes grade III’ and prescribed B-12 injections, “no brisk walks” and also suggested that I meet someone for herbal potli treatment. My next visit was to an old school orthopedic surgeon who too ruled out surgery, felt that the ‘meniscus tear’ was not a problem if I wasn’t jogging/ running and advised a knee brace support while walking, a spray, good old ‘seven seas fish oil’ capsules, etc. Even more confused, I met a fourth specialist who felt that my case was “far from a surgery” and the problem could possibly be resolved by some injections—either synthetic or protein rich part from my own blood or stem cells. By now, I was ready to write a thesis on the ‘finer nuances of pain in the calf’ but decided to first meet my neighbourhood physiotherapist. His prognosis was truly heart-warming. “Sir, you are not likely to need a TKR for at least ten years. Just have a couple of sessions with me and God willing you should be fine.” Sure enough, eight sessions of thermal, ultrasound, vibration, manipulation, etc. did give me a lot of relief. Five years have passed and I am doing my usual walks, haven’t had to visit the physio more than perhaps 5–6 times, do some daily exercises at home, and life is pretty much back to normal. Of course, I have no clue what is in store tomorrow.