The World Health Organization is observing the World Health Day on 7 April 2023, on the occasion of its 75th birthday. This year’s theme is “Health For all.” The WHO claims it to be “an opportunity to look back at public health successes that have improved quality of life during the last seven decades. It is also an opportunity to motivate action to tackle the health challenges of today ̶ and tomorrow.” The world made great stride during the last seven decades with advances in the medical science that improved the quality of life. Yet, when Covid-19 pandemic hit, the entire world was at its knee. Even the developed countries were not spared. Covid-19 exposed the lacunas in the healthcare sector uniformly across the world. Even though the exact source of Covid-19 is not clear, it has all the signs of being a man-made disaster. The world must learn from this debacle and tackle such challenges at present and in future efficiently.
India’s contribution to healthcare is abysmally low at 1.14% of the GDP, given its huge population. Majority of the healthcare spending is out of the pocket (50%), and any catastrophic illnesses will drive the population down their social strata. Yet there is a silver lining in the dark clouds. Kudos to the ICMR and the Government which firmly stood behind it, India has managed Covid-19 exceptionally well. According to a draft paper from Stanford University, India saved 34 lakhs lives and had a net benefit of 15.42 billion dollars through vaccine campaign. Besides, India epitomized a unique leadership role by gifting the vaccines to the world at large. Therefore, India is in a position to lead the world towards an optimal healthcare delivery at reasonable costs if it uses its resources, technology and people appropriately.
Big Five of Indian healthcare resources are the human resource, pharma and vaccine industry, cost leadership, digital technology and private hospitals. Another big five, the country lacks is research and innovation, medical technology, data management, quality standards, and doctor-patient trust factor.
India produces the best doctors, nurses and other ancillary medical personnel and their prowess is well established across the world. Now the GOI is on a spree to open too many new medical colleges to fulfil shortfall in healthcare personnel to match the WHO standards. According to our Hon’ble Union Health Minister, recently we have closed that gap also. However, medical care is a team work that requires several other support staff, and that manpower also has to be developed at appropriate proportions. Besides, the quality of medical education needs to be enhanced. The health being a state subject in our federal structure, the state governments have to create more jobs, to accommodate new graduates. Otherwise we will be producing more doctors than the jobs available, leading to brain drain.
Now India has emerged as a Pharma giant of the world. However, most of the production is based on the borrowed formulary and there is little research and development. Despite being major pharma producer, the people of the country are not getting the benefit of cost. The GOI’s ambitious project, Jan Aushadhi centres selling generic drugs have failed to reach the masses. Besides, recent deaths in Gambia due to Indian cough syrups is a major red flag for the quality of medicines India produces. The GOI has to swiftly act on R&D, quality standards and prices of ‘Make in India’ drugs. The vaccine industry must learn from the Moderna, and use the mRNA platform to develop solutions that can prevent genetic disorders as well as viral infections.
Aravind Eye Hospital and Narayana Hrudayalaya have exemplified that we can achieve excellent economy of scope and economy of scale by applying lean management principle and mass production system to achieve cost leadership and sustainable competitive advantage. Many Indian hospitals performing major surgeries at 1/10th the cost of western countries. However, these principles are not being universally applied across healthcare industry, and whoever have applied, are not passing on the cost benefits to the patients. India has largest population at the bottom of the pyramid envisaged by management guru, C. K. Prahlad. Indian healthcare industry has a lot to benefit by servicing this population through cost leadership. Besides, Indian can teach the developed countries who are struggling to contain healthcare costs.
Another area where India has emerged as a titan is in digital technology. However, digital transformation is limited to financial sector and most of the developments are exported to service foreign companies. Even though, few corporate hospitals are on the path to embrace it, it remains only in major metros, and not reaching the places where population at the bottom of the pyramid are located. Most importantly, the government health sector still lags far behind. Digital transformation can save a lot of cost and the country must utilize this core competency to serve the people of the country.
As such Indian health budget is low, the private health sector is major backbone of the country and service the 80% of the healthcare needs of the country. Major private players are ‘ma-baap ka kirana store’ like clinics or small nursing homes. The governments could have used this sector through an appropriate public-private partnership to cater the masses. Unfortunately, the country is treating these major healthcare deliverers poorly through license raj and draconian laws, such as the one recently passed by the Rajasthan Government. This is a desperate step by the self-centric politicians who have failed to provide for the people. These small players are also under the fear of being swallowed by the corporate honchos, like malls swallowed the kirana stores. Corporatization of the healthcare will drive the healthcare costs skywards. Hence, the Governments should incentivize the small players and help them with single window license approvals and tax benefits.
Coming to the deficits, first of the major big fives India badly needs is research and innovation. Most of the Indian scientific publications are of poor quality and value publications are emerging only from top institutions such as AIIMS, PGIMER and IISc. The thesis topics in most state medical colleges are either of poor quality or repetitions. Concerned authorities must encourage and reward original research and enhance research funding.
Major capital expenditure in healthcare sector and also a major trade deficit to the country is medical technology. Of all the revenue from healthcare sector, only a 9% comes from medical equipment business. Sad truth is, many Indian companies research and develop most of the new medical technology for foreign companies on consultancy/turnkey/service basis. Later, these products are manufactured in China. Despite having the necessary capability, India is not able to produce quality medical equipment, and promote “Make in India’ brand. The GOI and the private sectors have to act on this on a war footing. Even if we are able to sell our products to the third world countries, we can generate a big revenue to the country.
Now the data is the king and future business expansions, decision making and revenue generation will be through data analytics and data driven developments. Unfortunately, the medical data in the country is generated only by a few institutions and that too is fragmented. Given its huge population, the country can be a source of huge data. There, the country has to use its digital capability to coordinate and develop a unified data collection and analytical system without violating individual privacies.
In the last decade, India has done very well on the front of Medical tourism and majority of it can be attributed quality standards of corporate hospitals and accreditation agencies. India has a potential to emerge as a major healthcare provider of the world if the quality standards become universal. It is a wrong misconception that, quality comes at cost. The truth is contrary. One of the ways to reduce the cost is by enhancing the quality. The lean management and Toyota production system (TPS) have proven that the costs can be brought by enhancing the quality in automobile industry. The TPS can be applied to the healthcare industry also. Besides, the governments have to create good infra-structure to attract more tourists. And there should also be stringent laws to curb the exploitation of international patients.
In a country where people revered doctors as gods, now suddenly there is a change in perception. Entire medical fraternity has to work hard to regain back the Patient: Doctor trust factor. Some of the root causes of erosion of trust factors are commoditization of healthcare and a lack of clinical acumen in new generation.
Even though corporate hospitals brought quality healthcare to the country, it also resulted in commercialization and commoditization of healthcare. The corporate hospital marketing teams who conduct their quarterly reviews at five star facilities, factor the patients as number of units. This is a dangerous trend that pushes the medical personnel to unethical practices. This trend has to change.
Now the current generation is relying on diagnostics and investigations more than their clinical acumen to arrive at a diagnosis. This is attributable to change in attitudes and highly competitive nature of entrance examinations which is driving students to books than patients. The new medical jargon, the evidence based medicine and the rising medico-legal issues have further added to this changing trend. Hence, bedside learning needs to be re-emphasized. Purely theoretical entrance examinations have to be transformed to clinical oriented assessments in the lines of USMLE or PLAB.
Overall, the size of the Indian Healthcare Industry was expected to reach 132 Billion dollars in 2022. Medical tourism market alone is expected to contribute 13 Billion USD by 2026. Other than the factors enumerated above, the GOI has to enhance the healthcare budget and engage the private players in an optimal public-private partnership, protect the doctors and create a win-win scenario for all stakeholders. On the other hand, doctors and hospitals have to practice even greater empathy in patient care, enhance their clinical skills for patient centric management and transparency in billing to regain the patient: doctor trust factor. By changing its priorities and practices, India can definitely become a global leader in Healthcare Industry.
Prof. Dr. Prahlada N.B
7 April 2023