Tuesday, 12 November 2013

Indian Health: Money and Doctors Cannot Solve It - Get the Engineers Out There

India's recent mission to Mars seems to have provoked questions mainly from non-Indians on the need to prioritise development in other areas such as healthcare. Most Indians seem to be proud of the Mars mission and live on hope that the great successes seen in space exploration may somehow be replicated one day in other areas. Many non-Indian commentators and overarching international organisations have asked for India to raise healthcare spending.

The numbers seem to be all over the place. For the purpose of this blog discussion we will assume the following for Indian healthcare expenditure:

Percentage of GDP spent on healthcare 4%

Percentage of government expenditure on healthcare 8%

Per capita spending on healthcare $60 (if you believe wikipedia its $124)

Out of pocket expenses is around 60%

This is when the arm chair commentators, the ones who have never been bitten by a mosquito in an area where malaria is prevalent, should get out of the discussion and get a dose of reality.

What can you get in western healthcare for $60? Not a lot. 

This $60 per person per year spent on Indian healthcare is mostly accounted for by the 20% of people who represent the middle class and above. Many of the middle class get much more than $60 spent on them leaving in theory and in practice, a large proportion of the population to have nothing spent on their healthcare $0 per year. A friend recently had a colonoscopy in a frightfully expensive hospital in India and spent Rs 70000 ($1111) this may mean this friend has used up 17 other Indians' annual healthcare spend. You get the picture.

70% of the Indian people live less than $2 per day (33% of people are below the official poverty definition of $1.25 per day). You get the bigger picture.

By how much should India raise its healthcare expenditure? Doubling it to $120? What would that get? Nothing in reality. Doubling that to $240? You would not even scratch the surface. If the entire per capita income of an Indian which averages $1100 is spent on healthcare India will still have a healthcare expenditure less than Lithuania. Even at that level no one can predict if healthcare benefits will be equitably distributed across the population. It may well be possible that the rich will get healthier and the rest may get unhealthier.

The US example is relevant here where 18% of GDP is spent on healthcare at nearly $9000 per person yet 40 million US citizens do not have healthcare cover and US has poor outcomes for many chronic conditions. Throwing money at problems does not necessarily solve problems. 

Ask for a better system. Ask for a different system. If that system costs a little more, then the money follows, do not ask for more money to be spent on the existing system - it just goes down the drain.

Copying the current western systems of the 21st century for healthcare delivery in India straightaway  is expensive. This means the benefits of any copied western systems will reach the small proportion of the wealthy population. Well worth remembering the Jaguar in India costs the same as in England and obviously the only wealthy get to use it.

Alternative medical systems (ayurveda, siddha, homeopathy, etc) are still unable to provide comprehensive answers at a population level.

So what is missing? What are the potential avenues to explore?

Cannot Escape Evolution

There can be no doubt health improvement at population level has evolved gradually over time from the early 1900s. Interestingly the earliest foundations of population level health improvement happened not by direct personal medical based interventions but by infrastructure based social living conditions improvement. I am talking about covering the drains, separating animals from human beings, providing clean drinking water and so on. Direct intervention based healthcare followed much later.

In India in 2013 there are still many areas even within all the cities greater boundaries where there are open sewers. In 2013 in one of the poshest areas of a very major city there are contaminated water supplies. The healthcare budget cannot not solve this; yet solving it will improve the health of the people.

A healthy population is the greatest boost to an economy but the population cannot be made healthy by primary, secondary or tertiary care based direct personal medical interventions - i.e. doctors, clinics, hospitals. Populations can be made healthy only by political will and civil engineers. That is the trick India is missing. Building more primary and secondary care centres with open drains around them is the opposite of a decent healthcare solution. India cannot hope to improve the health of the population by avoiding a well established evolutionary pathway.

It seems India and its well wishers may be looking for the magic injection that will solve major health problems. There may be magic injections for diseases but we will do well to remember that there are no magic injections for health.

Under the given current conditions, doctors cannot solve the healthcare problem of India. Get the engineers out there. Get them to cover the drain, clear the puddle, provide clean drinking water and keep the roads clean. You will find the population becomes healthier contributes effectively to the economy. Then and only then we can spend more on healthcare and expect to benefit from it.

Follow me on twitter @HemadriTweets
I have blogged previously about great areas of Indian healthcare which you may want to check out.
Dr Bang's remarkable achievement in rural India which gets the same results as cities

My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture


JK said...

You should not forget about nutrition. I feel that the burden of disease in the Indian subcontinent can be brought down to a large extent by focusing on food security. However, we need to address issues which you mentioned in your post. It is quite interesting that public healthcare can only be achieved by focusing on the socio-economic determinants of health. Having more doctors and nurses alone does not do any good.

M HEMADRI said...

Thanks for your comments JK.

You are absolutely right, nutrition is of prime importance. Nutrition keeps the population healthy and a population that is generally healthy would seek out better nutrition as well.

I would argue though that currently it is general sanitation and hygiene should take a higher priority as preventable infectious diseases are continuously defeating the benefits of nutrition and personal intervention based healthcare.

Saji Manuel said...

Excellent.I appreciate the mammoth effort you have taken to assimilate the data.I had been practicing in remote India for 13 yrs and has been now practicing in Australia.If we are planning to implement the system here which is struggling by taking care of mostly aged population mainly by bureaucrats and computers rather than doctors, it will be like stretching legs before sitting.Economic sustainability of a country depends on middle class wealth and poor class welfare not by high class wealth like wise the health care sustainability of a country depends on the health of young age and middle age.There comes the role of social science which should help to do research to implement healthy social behaviors in society,no just imitating what is there inn developed countries.There comes role of complimentary medicines and non corrupt,non jealous attitude of doctors,minimal bureaucratic interference and positive political Will power.The life style changes evolved through centuries of reaserch still hiding in many Indian books are more relevant in developed countries with rapidly increasing metabolic syndromes,compared to 1-2 centuries of research of like style changes and social life which here they are trying hard to drop out due to negative effects like bowel cancer,alcohol,drugs,obesity.May be we need some refinement and research of those life style ideas for the current technological word since we can't wait for few more centuries for the evolution of those ideas through generations.

M HEMADRI said...

Well said Saji

Unless there are breakthrough innovations with new ideas, India and similar countries will only play catch up for ever.

sam said...

very good article,
agree that engineers have the key to establish health in India .they have a greater role to play in terms of implementing better technological reforms and bringing transparency in the society .

M HEMADRI said...

Thank you Sam

A friend from India has suggested half in jest, that engineers should also perform rural service.

I think that is good idea if engineers worked in rural areas for a year, with defined budgets, tasks and locations to solve this problem, before they are signed off from their colleges/universities and eligible to receive their degrees

Anonymous said...

Engineers might be able to help, but they can do only that much.

The only people who can make real a difference are the politicians - But are they going to help help? - Unlikely.

Our GDP is 10th best in the world - but the amount of money we spend on health care is 178th. We can`t expect a good outcome with that sort of money even with the best efforts of our planning, engineering and health care team.

We defenitely need more trained doctors and allied health care professionals. India is a country with one of the lowest doctor/patient ratio - we have less than 1/1000 where as WHO specifies that it should be more than 4/1000. We have about 8 Lakh doctors in Modern medicine working at presentin India but about 1 Million positions remains unfilled according to govt estimates. We train enough doctors, but they are not ready to stay and work in India as they are not happy with the pay package, especially in the rural areas.

More than 90% our rural people do not have access to a trained modern medicine doctor.

Goverment got enough money to solve the issue. But they seems to be interested in political gimmicks lika Mars mission to hide their shortfalls.

M HEMADRI said...

Hi Anon (0137)

You miss the point of the blog. Political will is essential and some amount of money is of course needed. But I have already made the point that even if the entire per capita earning of India was spent on healthcare, India would spend about a third of what UK spends. That is why looking at GDP or ranking tables is a bad idea.

We need infrastructure development on hygiene and sanitation. At this point of time it has the highest leverage in improving healthcare.

Pitar said...

Glad to read this informative blog. i would like to give special thanks to the author.