Indian healthcare: The needs and demands

For the next decade, healthcare providers and experts recommend a system that focusses on continous improvement and sustainability of businesses in the long run By Akanki Sharma

India’s healthcare scenario seems to be at crossroads, where there are some positive achievements on the health indicator, but suffers some serious shortcomings in care delivery. The country has been successful in eradicating polio, reducing epidemics caused by tropical diseases and controlled HIV to a large extent. However, it still faces a huge economic burden due to NCDs, struggles to balance accessibility, affordability and quality and is unable to hike public health budgets.

In order to strengthen healthcare delivery and improve business prospects, policy makers, healthcare providers, business leaders, technology providers and pharma companies will need to device strategies that transforms a spark into a sustainable fire. Here are insights from healthcare leaders that can lead India towards a healthy tomorrow.

The current scenario
Amidst the efforts going on, there are several challenges in the current state of healthcare in India, according to Raviganesh Venkataraman, CEO, Cloudnine Group of Hospitals. Some of these 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, he further says.

He suggested that use of decision support systems and technology is critical to solve issues. “When we have limited resources and limited supply of skilled caregivers, it is necessary to find ways to use technology to maximise 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,” Venkataraman points outs Dr Ashutosh Raghuvanshi, MD and CEO, Fortis Healthcare shares, “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 recognised, and India is the chosen destination for international patients with often incurable disease conditions, who find the right medical solutions in India. With the launch of Ayushman Bharat — PMJAY in 2018 (world’s largest government healthcare scheme), 50 crore marginalised 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.”

In his opinion, 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.”

Just like Venkataraman and Raghuvanshi, Dr Naresh Trehan, CMD, Medanta — The Medcity, had a view that even though the Government of India is trying hard to provide better healthcare to its citizens, they are deprived of the access. “Despite the government’s efforts, majority of our people remain deprived of access to healthcare, especially at the secondary and tertiary levels. In addition to this, there are challenges of affordability, accountability and the dual burden of communicable and non-communicable diseases. Across the healthcare spectrum, lack of infrastructure access, skilled professionals, quality,  patient awareness and use of health insurance are lacunas,” he lamented.

For a healthy India, he suggested, “We need preventive and/or promotive health: prevention, early detection and treatment. A strong primary healthcare system will lead to a healthier India while helping us manage the country’s health better.”

Dr Ramakanta Panda, Cardiovascular Thoracic Surgeon and Vice Chairman, Asian Heart Institute, had a view that 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,” he said.

He further added, “In terms of affordability, healthcare is a calamity that throws an afflicted family into the jaws of poverty. About 55 million Indians were dragged into poverty in a single year due to patient-care costs, according to a study by the Public Health Foundation of India (PHFI). 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, focussing on patient education and prevention.”

According to Dr Panda, the current biggest challenge India’s public and private healthcare sector is facing is revolutionising medical education. “A student pursuing medicine has to 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-speciality like cardiology, neurosurgery, etc. This alone does not suffice and they have to 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 rupees for an MBBS seat or more than Rs 2- 3 crores for post-graduate seats. We have to ensure that medical education is affordable. Apart from that, the government must also allow private hospitals to train young doctors in super-specialities,” he asserts.

Raising the biggest issue that afflicts both patients and providers, Sumit Goel, Partner – Healthcare Advisory, KPMG India, speaks about the trust deficit between patients and healthcare service providers. “Studies estimate that only two in five patients believed that hospitals acted in their best interest,” he notified. He further speaks about the reasons for which hospitals struggle to stay afloat. “NCDs require possibly long-term care to be provided in out-of-hospital settings such as at clinics/patients’ home or at any place of patient’s convenience. However, the sector, in its current form, is designed for hospitalised care.

Insurance providers, be it government or 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,” he states.

Policymaking — A cause of concern?
Policymaking is certainly one of the most important aspects for providing effective health services. Venkataraman says, “The problem in India is fundamentally of supply than demand. Policymaking has to 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.”

As per Goel, 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, suggested Dr Raghuvanshi. He said, “In 2019, the government has notified all medical devices under medicines, and not under a separate Act. There are caps on the prices of cardiac stents and orthopaedic knee implants. It is always viable to have a roadmap for a comprehensive policy formulation in consultation with the hospital sector and other stakeholders. In addition, with 80 per cent import dependence on medical devices, we need to have a rational approach to ensure quality products for the best patient outcomes.”

Strengthening public health
The Government of India has introduced several programmes to provide better care to its citizens. Ayushman Bharat – PMJAY, the non-communicable diseases programme, the communicable diseases programmes on tuberculosis (TB), malaria, HIV and the National Tobacco Control Programme, the Pulse Polio campaign or the national immunisation programme, have done commendable work. However, more needs to be done.

Dr Raghuvanshi points out, “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’s not a single policy, but interconnected, multi-pronged thinking that is needed. In addition, India is now in the midst of 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.”

In Dr Trehan’s view, 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. For instance, in view of the current TB burden in India, a lot needs to be done if we want to eliminate it by 2025. India has the highest burden of both TB and multi-drug-resistant TB with a huge number of cases that are not notified or remain undiagnosed. Active tuberculosis patients need assessment of their nutritional status at diagnosis and throughout the treatment. The government’s decision to allocate Rs 600 crore for providing nutritional support to all tuberculosis patients would mean better cure and higher treatment completion rates and overall better performance status. Further, 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,” he said.

Drawing attention towards the rising cost of healthcare, Dr Trehan also said, “The high cost of healthcare and out-of-pocket expenditure force families to sell their assets, pushing nearly 60 million people every year into poverty. To maximise benefits, it may be wise to establish a link among various health initiatives announced in the budget and also with related programmes like the National Health Mission. Clarity is also needed on what services will be provided by the government health facilities, for which conditions patients will have to use private parties and what mechanisms are available. There is a need for uniformly pricing systems for various health interventions, including diagnostics and medicines and ensuring transparency. A continuum of care systems also needs to be established by linking hospitals with health centres and with the community. Community engagement is thus crucial in planning and implementation of the programme. They must also ensure that health and wellness centres and primary health centres are responsive to the needs of the community.”

Dr Panda further pointed out on the manifesto of the Budget 2019 which stated that close to 10 lakh patients have benefitted from free medical treatment via Ayushman Bharat, which would have otherwise cost them Rs 3,000 crore. He also said that lakhs of poor and middle-class people are also benefitting from reduction in the prices of essential medicines, cardiac stents and knee implants, and availability of medicines at affordable prices through Pradhan Mantri Jan Aushadhi Kendras. “By 2030, the government has expressed commitment to work towards a distress-free health care and a functional and comprehensive wellness system for all. This is a lofty goal and we must support the government in whatever way possible,” he emphasised.

Access to quality medicines
It is often said that quality, safety and efficacy of a medicine is a must. In keeping with this, Goel, said, “There are two intertwined issues — one is how to ensure that best quality medicines are produced and that the integrity of the drug is maintained during the distribution process; second, how it can be ensured that quality medicines are affordable, so that they can be accessed when needed. The first issue requires strengthening of quality standards and their strict implementation so that there are no two different quality of drugs — one for the developed regulated market, and the other, for the Indian market. To address the second issue, it is important to make quality generic drugs available to patients. Government and some startups have taken steps in this direction by opening a chain of retail pharmacies which dispense only quality generic drugs at a fraction of the cost.”

Dr Panda told that an estimated 469 million people in India do not have regular access to essential medicines, according to the WHO. Easy availability of essential drugs is critical for India’s healthcare system. Indians are the sixth biggest out-of-pocket (OOP) health spenders in the low-middle income group of 50 nations, as per a May 2017 IndiaSpend report. “Around 70 per cent of the overall household expenditure on health is on medicines; which is an important factor contributing to poverty,” he said.

Venkataraman added, “On one hand, healthcare is largely financed through out-of-pocket payments and on the other, access to the right doctors, facilities, treatment and medication in a timely manner is limited to a few metro cities, and thus, large parts of the country lack this access. India has a reach and access issue for most products. The starting point of solving this will come from the acceptance of the fact that pharma is a business and not a charity. We need the government and the pharma companies to work hand-in-hand and arrive at a model that resolves the commercial and the social objective.”

He also expressed his concern saying, “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. On the policy side, the Indian government has made a bold commitment to achieve Universal Health Coverage (UHC) through Ayushman Bharat, which aims to provide affordable healthcare to the entire population and reduce their expenses on healthcare.”

Amidst various issues Pradhanmantri Bhartiya Janaushadhi Pariyojana (PMBJP) has come up as a relief for many who are dependent on generics and can’t afford branded medicines. In this regard, Raghuvanshi said, “The presence of a large number of generic drug manufacturers in India means that essential drugs should be widely available across India. The Government of India has, through its Jan Aushadhi scheme, made a large-scale effort to make medicines available at affordable prices at pharmacies across the country. However, accessibility remains an overall challenge which needs to be tackled at various fronts. Primary healthcare centres need to be strengthened, incentives need to be given to generic medicine manufacturers, pharmacists and supply chains. Public-private partnerships can provide some solutions on this issue. The role of the national regulator needs to be redefined to that of a facilitator. Technology and start-up incubators can play an important role here by creating new platforms for medicine supply and distribution.”

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 optimising 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 optimisation and operational management information system (MIS), which otherwise is labour-intensive and prone to human error,” emphasised Dr Trehan.

He also mentioned the significance of telemedicine, which, according to him, is of immense benefit to patients in remote locations. “Offering convenience, it helps them to gain access to doctors without physical travel. This aids 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,” he informed.

Raghuvanshi is also in favour of technology. He replies, “Technology is transforming the healthcare sector in India. It can improve our long-term health by tackling a number of 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 personalised environment for both patients as well as healthcare providers. Many healthcare experts anticipate that operationalising AI will result in a 10 to 15 per cent increase in productivity over the next two years.”

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 utilisation and self-care programmes, 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,” he added.

Getting a little deeper into technology, Venkataraman said, “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 digitalisation.”

The importance of digital tools in healthcare is significant, as referred by Goel. He said, “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 through the use of 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. Venkataraman had a view that private-public partnership is the only way to solve India’s healthcare problem. The starting point for this, as in any partnership, has to be mutual trust and a recognition that the solution has to be a win-win for both.

According to him, there is a global crisis in healthcare. “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 has to 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,” he predicted.

Speaking along the same line, Dr Trehan said that Ayushman Bharat can exercise a transformative impact if implemented in an effective and coordinated manner. “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 people. A continuum of care systems also needs to be established by linking hospitals with health centres and with the community,” he opined.

According to Raghuvanshi, Ayushman Bharat scheme is a radical shift as it reaches out to the poorest and the most vulnerable families, covering complex treatments, hospital stay costs, surgeries and procedures (in both public and private hospitals). “So far, 8,000 private hospitals have joined the programme but bigger, multi-specialty hospitals are yet to step in to empanel. Private hospitals are still in the process of reviewing the viability of the rates of the different packages that have been offered under the scheme. The National Health Authority (NHA) has been requested to review these rates as they are far short of even basic rates for quality and don’t cover even the direct costs of the surgeries. We will do our best to support in every way we can and look at different means of contributing or participating, such as offering skill training or education programmes,” he informed.

When asked about the government’s strategic plan to purchase services from the private sector, Dr Panda remarked, “This is a welcome move. 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.”

Key trends/policy interventions/innovations for healthcare 2020
In the next decade, India’s healthcare sector will see a more matured digital base and effective policy intervention will streamline processes within the system as well as ensure quality access.

“There is an 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. We can and I am sure will choose this path and chart a track completely different from what the rest of the world has seen,” Venkataraman stressed.

Goel expects that in 2020, policy interventions aimed to make healthcare more affordable will have the largest impact. The interventions include: scaling of already launched Ayushman Bharat, renewed effort by insurance companies to fix the pricing of healthcare services and expanding the coverage of Ayushman Bharat to include the middle class and senior citizens.

He elaborated that some policy interventions which could be triggered in 2020 to change the way healthcare systems are organised to enhance quality, accountability, patient satisfaction and efficiency in care delivery should include: quality measurement and improvement with public reporting of outcomes; interventions to support provider consolidation using strategic purchasing as a lever; corporatisation 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.

Dr Trehan, adds, “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.

Raghuvanshi brought into limelight the safety of healthcare providers for 2020. He said, “The Centre is ready with a draft Bill which makes assault of healthcare professionals a criminal offence with an imprisonment of up to five years and fine extending up to Rs 5 lakh. After numerous incidents of violence against doctors, the government has framed this important Bill which should become a law soon. The government is also considering lifting price curbs on new generation of stents more than two years after its directive on capping medical devices. A newly-constituted committee, headed by the Indian Council of Medical Research (ICMR), is reviewing if all drug-eluting stents (DES) are the same or whether a new category needs to be added. There is also a plan to base identification of patients on Aadhaar cards for maintaining health records. It also envisages a combination of health services access facilities through the India Health portal, My Health app and other social media platforms. These are all significant policy developments with respect to healthcare in India.”

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?

akanki.sharma@expressindia.com