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.

©M HEMADRI 

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  http://successinhealthcare.blogspot.in/2013/01/swadeshi-healthcare.html

My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture  http://successinhealthcare.blogspot.in/2013/04/my-conversation-with-dr-ravindran.html

Preventative Health Checks: Just because you could, doesn’t mean you should

“Just because you could, doesn’t mean you should” was a “mantra” given to me by one of my family medicine teachers and I have come to appreciate its wisdom over years. Over the last decade as a practicing clinician, I have come to realize the limitations of modern medicine, started seeing patients as people with different goals and values and have been trying to equip myself with knowledge of patient centered healthcare.


Preventive Health checks in India have gained popularity in last decade or two. As a practicing physician in urban India, I come across patients who have been getting the “health checks” year after year. A huge number of patients are “self-referred” and get annual check-ups in hospitals and diagnostic centers. A good number of these check-ups are also offered through the employers and I have seen patients in their early 20s getting routine health checks as well.


I looked up the health checks offered and they come in various forms. I asked some of my patients to look at these packages and tell me which one they thought was the best package for them. Some picked the most expensive package; some went by the keywords like “full body check-up” or “advanced” check-up. Very rarely do I come across patients who understand exactly the tests they have been getting and the appropriateness of these tests. While there are some hospitals/centers that have put some thought in designing the “health package”, a majority of them take the “shot-gun” approach of offering multiple tests that all the patients undertaking these packages may not necessarily need. Some examples are routine ECGs/ECHO in young adults, pap smears in women older than 65 years, routine abdominal ultrasounds in young adults etc. Some even go to the extent of causing potential harm, for example, cancer biomarkers for several types of cancer- many of them have been studied to cause more harm than good. Also, In patients at little to low risk for heart disease, an electrocardiogram or stress testing can actually lead to harm. However, they seemed to be a common component of majority of health checks.


A recent analysis from Cochrane review concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.” Due to missing or unreliable data, the authors could not estimate costs, harms, or the use of follow-up medications and testing as the result of screening. Although all the studies used for this review are from western context, I think this study brings out a whole new perspective on how we should look at the preventive health care sector in India.


I am a family physician who strongly believes that “prevention is better than cure”. I am a “prevention enthusiast” who believes preventive measures done right can not only add years to your life but also improve the quality of life. As Dr. John Mandrola says, “The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people, neither can screening tests nor pills.” Moreover, in most of the western countries, the preventive health care recommendations are offered and to an extent “tailored” to meet the patient’s risks as opposed to Indian setting where one can walk into any center offering health checks and get a whole host of tests done. So, if there is strong evidence showing general health checks do not decrease the risk of deaths from cardiovascular events or cancer, why are they so popular? Two of major reasons in my opinion are lack of patient engagement and education related to preventive care on part of family physicians and a “belief” held by majority patients that these health checks will make them healthy.


There has been extensive discussion following the Cochrane review and there are few things that one can argue upon as being beneficial. For example, Checkups can be beneficial in getting people to think about their health. Also, if the health check-up is being offered by your family physician, there is value in getting tailored approach to your preventive health check. There is also evidence for some meaningful screening approaches, such as screening obese patients for diabetes risk, patients with a family history of disease etc.


I guess, the bigger question, to ask is not whether preventive health checks are needed but how should they be designed so that they truly impact the lives of majority of people undertaking these health checks.


Dr. Danielle Ofri writes, “a detailed conversation is much more likely to uncover lurking medical issues than the physical exam or blood tests”. Even in the hospital setting, the advantage of detailed history and exam supersedes any combination of labs and imaging. You can see the results here and here. In my experience, however, these are two things most neglected and many a time skipped in most of the health checks being conducted.


Now, Let’s talk about the preventive measures that are backed by strong evidence but don’t make it to the preventive health checks: Counseling against tobacco and alcohol use, mental health screening for problems like depression and anxiety that are increasing in great numbers, obesity, infectious diseases (TB/HIV etc) and certain adult vaccinations etc.


So, Can we design a health check that can steer a patient towards wellness and just not give a “sickness free” check? Can we have a healthcare innovation from India that is disruptive enough to make a business case for “prevention” without relying on battery of diagnostic tests?


© Dr Jaya Bajaj
Guest Blogger


Dr. Jaya Bajaj is American Board of Family Medicine (ABFM) certified Family Physician with strong clinical and research background. She is a strong proponent and practitioner of patient-centric, evidence-based medical practice.

She graduated from ETSU Family Medicine Program, holds MPH in Biostatistics from University of South Carolina, Columbia, SC, and MBBS from Nagpur University. She also has completed Executive General Management Programme at Indian Institute of Management Bangalore.

She is passionate about improving patient care in India and believes technology can play a key role in bridging the knowledge gap. Dr Bajaj is the founder of HealthRadii, a healthcare networking site.

(Dr Bajaj's declaration: I am a family physician and this article only addresses preventive healthcare issues in adults.)

Swadeshi Healthcare

This was originally written for and posted at Healthradii (http://healthradii.com/guest-blog-an-example-of-swadeshi-healthcare/) now reposted here.

Swa =own, self, local
Desh = country/locality/region

Swadeshi = of one's own country/locality/region

Gadchiroli, Bangs and the wonder of low Infant Mortality Rates

Gadchiroli

Gadchiroli is a district in western Maharashtra. It is one of the most backward districts in India with a high level of tribal and deprived population. The terrain is tough with forests and floods; what ever little infrastructure suffers poor upkeep. In addition the area is infected with arms, ammunition, explosives with people willing to use these often; Naxalite related violence is a routine feature in the area. Currently there seems only two positive features to Gadchiroli, one of them is a general literacy rate of 74% which is far higher than the Indian national literacy rate of 59%.

The other is Gadchiroli's low Infant and Neonatal Mortality Rate. Clinicians could describe this as a a unique wonder, the faithful could describe it as a miracle. How is it, in an area with a difficult geography, backward population and extreme violence that the Infant Mortality Rate (IMR) is so low that it beats many 'developed' cities in India?

Come explore with me.

The Numbers

Around the year 2003 the whole of India Infant Mortality Rate was about 60 and India ranked 150 (out of 194 countries), Gadchiroli Infant Mortality Rate was 26.5 (which would equal a world ranking of about 100). That means the whole India IMR was a 100% more than Gadchiroli.

What is really interesting is in 2010 Indian Urban IMR was 31 with Delhi Urban IMR at 29. This means that the remote Gadchiroli had a better IMR in 2003 than Indian cities including India's capital have in 2010.

The neonatal mortality rate (NMR) in Gadchiroli in 2003 was 25. The neonatal mortality rate in 2010 for the whole of India is 33 (for urban India the 2010 NMR is 19).

Those are the basic facts highlighted.

How was this achieved?

Localism and operational research

By long persistent and consistent effort. It may be still be a wonder but it is certainly not a miracle. The research was detailed, hypothesis was based on local data and its analysis. The action that ensued was closely followed by continuous operational research and there was sequential building of hypothesis relevant to the local situation.

This means there was no direct transplantation of clinical pathways, technology or treatment from any so called best practice. Principles of public health research were rigorously followed to create locally optimum methods. The principles are universal but the data, analysis, hypothesis, action, pathways, care delivery methods were all local and specific to Gadchiroli.

Who did it?

Abhay Bang and Rani Bang; a husband and wife team both physicians with public health qualifications from Johns Hopkins decided to test and put theory into practice. Both have long family histories of concerning themselves in the matters of improving the lives of others. Just Google their names and be inspired.

What was the approach?

A holistic bundled approach. It is important to remember that these bundles were created on the basis of local data analysis. To put it precisely the Bangs for example found that local data showed sepsis/pneumonia, prematurity and hypothermia as the top causes of death. After a further analysis found in order of priority dealing with sepsis, asphyxia, hypothermia and feeding problems will reduce mortality with management of sepsis alone is likely to contribute to reduction of neonatal mortality by 50%. Tools for management was created after consulting with local population and delivered by village healthcare workers. The village healthcare workers were local resident literate women who were provided with a total of 12 months on the job training.

A 16 item Home Neonatal Care intervention package including management of asphyxia by bag and mask ventilation, injection of vitamin K, thermal care, early diagnosis and treatment of sepsis with two antibiotics (injected gentamicin and oral co-trimoxazole) were implemented. You can see the mind blowing results in the charts above. Over 15000 injections administered by these village healthcare workers and there have been no complications.

Every shred of evidence was local, every intervention was agreed with and co-designed by the local users, care was delivered by local people. No imported best practices, no national guidelines, no experts, no experienced care providers, no external or governmental monitors, to working to imaginary targets/predictions, no high technology, no huge amounts of money.................

The bundle approach did not stop with care delivery for neonates. Women's health was a closely inter-knit issue with child health and that was part of a bundle. Public education especially on healthcare issues was a part of another wider bundle. There have been equally immense successes in those areas.

A good quality of life is enabled by good personal habits and Gadchiroli happens to be one of the few areas in India where the public have recognised alcohol as not conducive to healthy living and hence demanded prohibition and help to keep the prohibition going. This is part of the public health bundle championed by the Bangs. I am positive if there was any way that they could reduce the violence in the area, if they had any power or influence on it they would have, I suspect they might have already explored it.

The Importance of the Bangs, SEARCH and Gadchiroli to the world of healthcare

When we think of healthcare in India most of us will be aware of Apollo in the corporate sector, Aravind Eye Care for brilliant innovation in ophthalmology, some pharmaceutical companies who produce affordable drugs for India and Africa, recently we think of Dr Devi Shetty's volume based quality improvement models; there are many more commercial names we could think of. We may think of medical tourism, we may even think of some traditional Indian healthcare systems such as Ayurveda and general health system such as yoga. While those are examples at the better end of the spectrum, we would probably avoid thinking of a greater cohort of diverse providers and their dubious ways.

We never think of Gadchiroli or the Bangs who have taken on a whole district with the poorest population and produced amazing results with meagre resources in an clinical area where everyone else in the whole of India finds it daunting. They are a triumph of public health, they are a victory of scientific principles of operational research, they are a beacon of localism.

Yet when I speak to many doctors in paediatrics, public health and operational management they are blissfully ignorant of this leading example. When I speak to paediatricians in India and paediatricians of Indian origin in UK, most of them are totally unaware of this.

It will be essential for every doctor in India and in every developing country to be fully aware of the Bang's Gadchiroli experience. When we talk of developing or delivering alternative models of successful healthcare that are specific to local needs there is no other learning resource better than Dr Abhay Bang's published material which clearly describes the principles of how to do it. These should be taught very seriously as a part of the public health curriculum in medical schools in India.

Aping the west, urban Indian healthcare providers should eliminate their mental block against anything local; they must develop some discipline in following the scientific principles of improvement and vision to own and deal with population health rather than client/customer health; that might help them improve the quality of healthcare in India. If you are Indian you have certainly heard the Gandhian word called 'swadeshi'; Abhay and Rani Bang are probably the greatest proponents of Swadeshi in healthcare, being Gandhians themselves that is hardly surprising what is relevant is that swadeshi has given India some top class results and lessons worth emulating in every area of Indian healthcare.

This is the Indian rural version of what Intermountain Healthcare does at Utah. I recommend the Bang method for India's healthcare improvement. I also recommend a Bharat Ratna for the Bangs.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

Dr Abhay and Rani Bang's SEARCH website: http://www.searchgadchiroli.org

India Infant Mortality Rate graph generated from the longitudinal data at http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate

India IMR and NMR for 2010 are from www.censusindia.gov.in/vital_statistics/srs/Chap_4_-_2010.pdf