Healthcare in India: On the Brink

Two speakers at the recent India Business Initiative conference offer radical suggestions for solving the country’s physician shortage.

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It may not be as hopeless as it seems. That’s the message delivered by Nachiket Mor, board chair of CARE India, and Srinath Reddy, president of the Public Health Foundation of India, at the recent Caring for Millions conference sponsored by the Chazen Institute of International Business and the India Business Initiative.

In fact, all the participants at the conference underscored the progress that India has made to attack deadly diseases, improve infant and maternal care, and improve sanitation, even as they acknowledged much has to be done. Mor and Reddy pointed out that India has a remarkable launching pad that no other developing country has. The advantages lie in the country’s edge in developing pharmaceuticals, technology, and in physician education. The problem, said the speakers, is not that India lacks the tools to provide healthcare. It’s that it exports them.

“We Have the Knowledge”

“Our industry already produces low-cost drugs and vaccines,” pointed out Reddy. (Companies include makers of pharma formulations and ingredients such as Sun Pharmaceutical Industries, branded and generic drug suppliers such as Lupin Ltd., and biotech companies such as Cipla Ltd.) “India is a host not merely to medical tourism but to pharmaceutical tourism. People come from Australia and pack suitcases with drugs that are made here. India is the pharmacy of the world.”

“Similarly, India is known for IT. For example, the Swasthya Slate, or "Health Tablet" in English, uses an Android tablet to conduct 33 diagnostic tests, including EKGs, and measuring blood pressure, blood sugar, and urine protein. The handheld device costs less than $1,000. Such technology has cut the turnaround time for maternal health care tests, for example, from 14 days to 40 minutes in Jammu and Kashmir, where it is being piloted as part of the National Health Mission.

Still, for the most part, India has not turned its digital expertise toward medicine. “The only systems in hospitals are billing systems,” said Mor, who complained that the fee-for-service approach means that the medical profession spends more energy tracking down payments than it does treating patients. “We need to be able to harness innovation, to put together the concepts of technology and healthcare.”

Then there’s the shortage of medical personnel trained formally in allopathy, defined as the use of medical and surgical interventions to combat and cure disease (as opposed to homeopathy, which works to stimulate the body’s own healing systems). Mor estimated that India requires about 1.2 million physicians to serve its population, “and we have something like 300,000 allopathic physicians.” Despite nearly 400 accredited medical schools throughout the country, he said, “the numbers being produced are not nearly enough to meet the requirements, and the situation is not helped by the fact that many migrate outside India.” Reuters called India “the world's largest exporter of doctors, with about 47,000 currently practicing in the United States and about 25,000 in the United Kingdom.

The lack of doctors is particularly acute in rural areas. Since “urban colleges don’t graduate rural doctors,” Reddy said, one solution may involve conversion of district hospitals into teaching centers. His proposal calls for local recruitment and full scholarships in exchange for five years of mandatory local service. Mor on the other hand felt that if physicians formally trained in ayurveda (which is focused on promoting good health rather than fighting disease) with at least a bachelor’s degree in the field, are retrained as primary care physicians, similar to the training of nurse practitioners in the United States, then India can fill the gaps at the primary care level even in the poorest parts of the country. District hospitals could then focus on taking physicians who already have a bachelor’s-level qualification in allopathic medicine and offer them two-year diploma in fields such as obstetrics, orthopedics, and anesthesia. This combined approach, in Mor’s view, would completely meet the requirements of trained personnel for both primary and higher levels of care.

But Is It Doable?

Both Mor and Reddy acknowledged that India has lost some momentum when it comes to healthcare. Nothing much has come from the 2010 High Level Expert Group on Universal Health Coverage that recommended upping public financing for healthcare from 1 percent to 2.5 percent of GDP. (The World Health Organization urges countries to spend at least 6 percent of GDP on health care.) “The economy slowed down, and the politicians argued that investment had to go to other priorities,” noted Reddy.

And even as progress continues on infectious diseases such as malaria and typhoid, noncommunicable diseases such as suicide, cervical cancer, and hypertension have reached epidemic proportions. Noting that Indians get heart attacks 10 to 15 years earlier than patients in the United States, Reddy pointed out that cardiovascular diseases are removing individuals from the workforce in their most productive years. “No country that positions itself as a growth area can afford to lose so many people in the productive prime of life,” he said.

Even if tax hikes are unlikely, though, the speakers saw reasons for hope. The country has been experimenting with innovative models such as the National Rural Health Mission. Launched in 2005, it has especially aimed to train health personnel in basic newborn care, resulting in a 1 million woman army of rural health activists who mobilize pregnant women to deliver at local health centers. The National Health Insurance Program for the Indian poor has enrolled nearly 185 million individuals, covering hospital care worth almost $500 per family.

What’s more, as India channels a higher share of tax revenues from the national level to the states, some localities are stepping up to make sure their citizens have health care and insurance. “The hope is that India can pursue changes at the state level. Then, over the next five years, other states and the national government will be able to implement lessons learned,” said Mor.

An important part of the state-level healthcare could come through public-private partnerships (PPP), the speakers predicted. Noting that the states don't have to provide the actual health care as long as they can assure someone does, Reddy added, “Past PPP schemes have been described as ‘Partnerships for Private Profit.’ Politicians need to redefine them as vehicles for the general good as Partnerships for a Public Purpose.” Beyond health benefits, such partnerships should offer opportunities to create jobs, especially for women.

Many pessimists refer to the crippling, enormous cost of healthcare for a country starting at such a low level. Without minimizing the enormity of India’s challenges, Mor called the comparisons with what developed economies spend on healthcare as “a bit misleading.” He noted, for example, that Indian heart surgery that costs $100,000 in the United States can be done for R100,000 (about $1,500), thanks largely to lower personnel costs.

“We have the resources,” suggested Mor. Whether India has the political and social will to launch a full-scale healthcare reform should become evident in the next five years.

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