Several of my expat patients are extremely impressed with the private healthcare system of India. They have never experienced anything like it back home! They rave about the efficiency, the cost, and the availability of quality care. Where else would you find a doctor consulting you in the comfort of your home for about the same fee you gotta shell out for a clinic visit back home? They want to know how we’re able to create such a super-efficient system that rivals the developed world in quality!
Here are some of my thoughts, based on my experiences working in India and the US, and my interactions with patients and doctors from around the world.. First let me simplify and clarify some things. We will be talking about these 3 kinds of health systems.
i. The American System: Very capitalistic, driven by insurance companies and large health care companies, high quality care delivered at a high cost, with minimal or no options available for the poor or uninsured.
ii. The European System: Very socialist, driven by the government, high quality care delivered at a medium cost, the same quality care available to every one in the country almost free, but with limited options and long waiting times for specialist consultations and elective procedures.
iii. The Indian System: Very heterogeneous, driven by out-of-pocket expenditure by families, variable quality care delivered at a low cost, with a multitude of options available to everyone in a free market.
So, let’s discuss now the above three systems in more detail.. I see three main ways in which the Indian healthcare system is different from the other two systems:
1. Choices: Indian healthcare system pampers the patient with a vast multitude of choices. A person with fever, cough, cold, and headache, can opt for home remedies, or get any medicines of their choice from a nearby pharmacy (home delivered!), or get advice over phone from their trusted family doctor, or visit a GP clinic, or visit a specialist clinic (such as ENT), or even visit a sub-specialist (say, a neurologist for their headache), all within the same day, without prior appointment or referrals. Lab sample will be collected at your home, and report delivered the same day on your email address! A person in rural or small town India might not have the same variety of options in their vicinity, but home remedies, herbal preparations, government services, and general practitioners (both qualified and unqualified) are present in almost every corner of the country.
Based on their paying capacity, personal preferences, and prior experiences with the health system, people make health-seeking decisions about these options and get varying degree of quality of service and care. These decisions are often driven by convenience, sociocultural norms and the prestige of each option within their community. Very few people are able to make a rational, informed choice – in fact, their confusion often increases if they try to shop around for the “best” treatment for their particular ailment.
This is in contrast to the American and European Systems where an almost uniform system is present, and “informal” options (unqualified providers, prescription medicines without prescription) are completely unavailable. Everyone gets the same quality of service and care, at about the same price point. Your choices for doctors and hospitals, and sometimes even treatment options, are limited to what’s dictated by the system. In the American System, those outside of the system (the poor and the uninsured) have almost no options, as the “list price” of services and products is prohibitively expensive! An emergency surgery can leave a middle-income uninsured person bankrupt!
Referrals to access higher levels of care in American and European Systems are often time-consuming and complicated. Typically the patients need to see their primary care provider (Family Physician or GP) who then takes a call whether a referral is needed or not. In the American System you could short-cut this process by paying extra, but this can get very expensive very fast. In the European System, long waiting times are the norm for non-urgent specialist consultations and procedures, although no-one gets left behind, except in very remote areas.
2. Minimal Oversight: Private Indian Healthcare operates with very minimal external interference. Any doctor with the basic qualification of MBBS can open a clinic without any legal requirements or registrations. In some states, one or two licenses may be required. Opening and operating a hospital requires several certificates and licenses, but overall it’s much less than what’s needed in the American and European Systems. There, it’s almost impossible to open a healthcare facility without the help of specialised consultants.
Doctors in India manage patients with a virtual free hand. There are no prescription audits, peer reviews, or benchmarks. Patient feedback systems are rudimentary, and mostly focus on the quality of service rather than the quality of care. In contrast, doctors in the American and European Systems are heavily constrained about what they can prescribe. The insurance companies or the governments constantly look over their shoulders, and keep suggesting changes, sometimes directly, and often indirectly, through monetary incentives.
Skill level of all healthcare personnel in India is highly variable, which in turn is a result of lack of oversight over training institutions. Most of the learning happens on the job, and even that depends on the learning culture at the place of work. Whereas, the training in the US and Europe is highly standardised, and ensures a well-defined minimum skill set before the person gets licensed to provide care of any kind.
The legal system in India is infamous for its delays, and is usually biased in favour of doctors. Professional organisations have the power to penalise errant health professionals, but rarely exercise this power. This is in sharp contrast to the heavily litigious American System, and the strict penalties often imposed by professional organisations over their negligent members, in both American and European Systems.
While this utter lack of oversight has led to proliferation of sub-standard, even hazardous care (pharmacies selling prescription medicines without prescriptions, unqualified “informal” providers everywhere), it has allowed healthcare organisations in India to keep overhead costs at a fraction of what it is for the other systems. Doctors practicing defensive medicine to avoid litigation in the American System is leading to impersonal, protocol-based care, and has driven up the system costs of health care.
3. Low Costs: Apart from lower overheads driving down running costs for healthcare organisations in India, there are some other cost heads which are significantly less compared to the other two systems.
Healthcare personnel work at much lower salaries in India compared to the other systems. The starting salary of a fresh medical graduate here is about 1/10th of what American and European medical graduates take home. Similar disparity exists for pretty much all other health care personnel. Even within India, salaries are much lower in small towns compared to large cities. Part of the reason healthcare personnel are working at such low salaries is because of much lower cost of living in India. Another reason is low government expenditure on health services, which keeps benchmark salaries quite low.
India doesn’t recognize any drug patents, and Indian pharmaceutical companies are free to reverse engineer and manufacture any molecule. On top of that, the government has put Drug Price Control on the Maximum Retail Price (MRP) of about 750 essential medicines. Recently, India also waived off the requirement to conduct research trials in India for new drugs that have been proven to be effective elsewhere. All this drives down the price of medicines to an extreme extent! As an example, metronidazole, an antibiotic, is priced at INR 20 (0.3 USD/Euro) for the whole 2 week course! The MRP of a 3-dose schedule of Hepatitis B Vaccine just INR 240 (3 USD/Euros). What’s even more interesting is that several of these medicines can be purchased from distributors at huge margins, and the healthcare organisations can decide whether to pass these on to the patients as discounts, or to utilize them to cross-subsidise loss-making units.
Is all this a case of “East is East and West is West, and never the twain shall meet “? It could be.. There’s an inherent hierarchy in the Indian society which is very difficult to grasp for the militantly egalitarian Western mind. We’re ok if people belonging to different socio-economic classes get different quality of care, according to their paying capacities. There’s always government services or charitable facilities for those who can’t afford the quality private healthcare services. Also, there’s a huge list of things Indian healthcare system ought to learn and adopt from the American and European Systems, and maybe a longer list of things that the American and European Systems should NOT learn from the Indian system. But this post is not about those. Let me share instead some innovations from the Indian System we can apply to the American and European Systems. In fact, we have a name for such low-cost low-effort quick-fix ideas – we call them Jugaad!
A. Innovations that increase access for the poor and the uninsured: Minimal oversight has helped several low-cost innovations flourish in India. Multiple organisations have trained women of villages as Community Health Workers (CHWs), providing preventive health and health promotion in their villages. This concept has since been adopted by the government and the last mile of government services are provided by an army of ASHA workers in Indian villages. In several remote areas of India and Nepal, trained generalists perform Caesarian sections and even abdominal surgeries, providing anaesthesia themselves.
Another interesting innovation that has worked in some areas of India is ownership by the people. In the state of Kerala, the Primary Health Centre is owned by the panchayat (the local government of the village), and there’s a large proportion of the funds that’s at the discretion of this local body. Several cooperatives have opened and run their own hospitals and clinics, providing free services and care to their members, and discounted services to other people living in their locality. The quality of care in these places is often better than nearby institutions!
Can there be a multi-tiered health system by design? Instead of trying to put everyone through a high quality but very expensive and often inaccessible health system, can we formalise different grades of care, regularly assess and publish their quality assessment results, and let the patients choose? Can the leaders at the centre relinquish the ownership of such systems, especially in rural, remote and vulnerable populations, to the people themselves?
The results might astonish us! After all, even with all the miracles that modern medicine claims to possess, we can only cure a handful of diseases, whereas almost 80% of ailments improve or subside with just supportive care!
B. Innovations that reduce costs without reducing quality: India is one of the few countries that require every product to be labelled with its Maximum Retail Price (MRP). There are no limits prescribed for what to print, but it does bring in some transparency in pricing, which is sorely missing in the Western healthcare systems. As a next step, it would make sense to introduce Drug Price Control on the list of essential medicines published by the WHO. Patents have expired for most of these medicines. A tablet of doxycycline does not have to be priced at USD 750, nor a tablet of albendazole at USD 400. (The Indian MRPs of these drugs are USD 0.01 and USD 0.5 per tablet, respectively). This simple step would make life-saving drugs affordable for a large section of poor and vulnerable populations in the West, and reduce costs for everyone else!
We need a paradigm shift from negative incentives to quality consciousness in healthcare leadership. With genomic medicine, targeted therapies and patient-centred care growing in importance, the future will see more and more of individualized care, with health care providers working in tandem with AI and robots. This means our age-old carrot and stick approach to quality assurance and adherence to pre-defined standards is no longer likely to work. Fortunately, we have other options, most of them allowing providers to assess and incrementally improve their own quality. Checklists have been shown to improve quality of care in various different care contexts. Self-audits by care teams, continuous quality improvement initiatives, patient feedback loops, result in high quality care at minimal costs. In these new contexts, the role of healthcare managers moves from supervision and oversight to motivation and mentorship. And the role of external agencies (government and insurance providers) moves to training of quality champions and fostering of innovations.
Technology is playing an ever increasing role in training, screening, and care planning. We can create remote training modules which can reach the remotest providers on their smartphones at a fraction of cost needed to deliver the same in person. Arvind Eye Care is using remote technology to screen villagers for eye problems and refer them appropriately. More and more care teams are using messaging apps to coordinate care, leading to efficient utilization of everyone’s time.
India has lots of innovations going on in personnel management. On one extreme, Arvind Eye Care has perfected the assembly line model, where each person is trained to do only one small aspect of a surgery, really really well. With an army of such assistants sourced from nearby villages and trained in-house, they’re able to save the time of the surgeons and the nurses, resulting in high-quality low-cost surgeries. On the other extreme, primary care clinics rely on multi-functional assistants to cater to the ever-changing primary care needs of their community of practice. Having one trained assistant taking care of everything from reception management, billing, and minor procedures to sample collection, dispensing medicines, and home visits, not only reduces the operating costs of the practice, it increases the stickiness of the staff, building a strong relationship with the patients and families. Gradually they can grow into management roles, as well as patient education and training roles.
For all this to happen needs a cultural change in the American and European Systems, where healthcare services are delivered in an environment with much less restrictions, oversight, and fear of litigation. We need to move from defensive care based on standards to participative care based on relationships. The onus of maintaining and improving quality ought to rest on the care teams themselves, and the communities being serviced by the teams.
C. Innovations that increase choices: It’s a contradiction in terms the way the American and European Systems operate within fiercely capitalistic free market societies. The American System is getting more and more consolidated in the hands of a few giant corporations, whereas in most of Europe, the government has taken a much larger role in healthcare provision than it has in any other aspect of people’s lives. The simple antidote to both these maladies might be to encourage more competition!
The West needs more pharmaceutical companies who can manufacture drugs with expired patents and flood the market with competitive pricing. They need more individual clinics and hospitals nestled within communities, and continually evolving and innovating to respond to the communities’ needs. They need more technological innovations democratizing access to healthcare information, diagnosis, and even management.
The governments can support these initiatives with subsidies, collateral-free loans, tax benefits, and other financial incentives for new entrants. They can protect these initiatives from litigation, licenses and insurance oversight for the initial few years of their growth, or if they’re servicing vulnerable populations.
I don’t claim to have all the answers. As a Family Physician, my hunch is that the solutions to the world’s problems lie in helping people develop their own solutions, rather than prescribing solutions from a central place. Let’s visit a neighbourhood clinic run by an informal provider in the back alleys of an urban slum. It might teach us more about “Health for All” than all the high-flying deliberations in air-conditioned seven-star hotels have done so far!