An article on Indian Healthcare

1. Confronting Commercialization of Healthcare
Recently I came across an interesting book, “The People’s Health Sourcebook”. Section 5 of this
book was of particular interest to me, I have used its title as the title of this article, I am a
healthcare architect with by and large corporate clients.
I am encouraged to quote extensively from the book by the authors themselves, they say:
“Any part of this book or the entire book may be copied or translated or used in any way provided it
is not used for profit or commercial purposes.”
Well I will get paid a few hundred rupees for this article; I hope the authors will not grudge me that.
I would just like to examine their thesis in the light of my experience of working closely with
corporate healthcare providers in designing their hospitals. Being an architect and a very visual
person myself I am delighted to re-present the very good visuals they use to make their point, the
first one of which immediately follows:
The text following this is:
“Only 22% of the health expenditure is public funded in India as compared to 44% in the US, or
95% in countries like Sweden or 75% in all the market economies of the world taken together.”
And then Uncle Sam tells us:
“But there are lots and lots of problems with this simple solution: What are the popular causes for
dissatisfaction against doctors and the delivery of health care in India today?

2. We have now half a dozen very cynical doctors, grimacing…
“These causes are leading to an increasing alienation of the community from the Medical
profession, which is a very unhealthy trend.”
“Yesterday, all my troubles seemed so far away…” warbled the Beatles. Little did they know they
were singing about Indian healthcare delivery systems.
My family doctor as a child was very much a friend of the family. Much more than a friend really,
he was treated as a demi-god…The medicine was dispensed in little paper twists, and seemed to
be a mixture of some or all of half a dozen powders for any illness…

3. The corporate hospital below is architecturally unappealing, but the point gets made: a drain for
money…(don’t miss the security guard). Quickfix hospital indeed.

4. Ah, the problems of the GP…but he bears them manfully, he is most preferred after all.

5. The breakeven analysis, a French phrase for something unmentionable…guess I’m incurably
foulmouthed. Let us pray to the gods that be that nothing ever breaks even, perish the thought!
The book goes on to say:
“A corporate hospital is run like an industry! It is run to maximize returns on investment. The
number of people who need investigation will invariably be less than that needed to break even –
especially as more and more hospitals will open. Where there is a high return of investment in any
sector in a market economy, more units of that type develop. However this will not push down
costs or promote efficiency. It will rather promote more unnecessary investigations, unnecessary
hospitalization, unnecessary surgeries and unnecessary referrals. Some of these are done as
malpractice. But a greater trend is to shape modern medical science so that there is more and
more “need” for investigations, hospitalization and surgery. For any other commodity if there is
competition the price will stabilize around its value. But since no value is too high for human life,
the ability to price is limitless. It is limited only by the ability of the consumer to pay.”
Strong words. I would, by and large, disagree. Let me tackle it point by point, and present my
viewpoint on the rhetoric above.
An exclamation mark after industry indeed! “Maximize returns on investment”, do I need to wash
my mouth out with soap again? What was wrong with the Indian mantra after Independence?
Among other things, it set up a huge, inefficient public sector (including public healthcare) to which
it denied autonomy of working; there were low to no “returns on investment” (excuse all this
obscenity) and we had a poor capital-output ratio. It also pampered organized labor to the point
where productivity became extremely low. All the rulers of our country did was institutionalize
democracy, in the name of the poor. Indian socialism ended up doing very little for the poor.
Ideology is not the solution, better management and more especially incentives to manage better,
are.

6. A high return on investment in healthcare? To succeed in the 21st century, healthcare providers
need to respond to the looming threat of competition and capitation. “…will not push down costs?”
The impending advent of insurance and health maintenance organizations will usher in managed
care. Where policy-led reform failed, market-led reform may succeed. The driving force in
healthcare is going to be an economic message of managing care, managing cost, and managing
clinical efficiency to create a sustainable healthcare delivery system for India. For us who are
marketing design services, we can already see a shift in the customer. The customer in the past
has been the hospital. More recently it is becoming the medical group and tomorrow’s customer
will be the health network or even a HMO.
“Some of these are done as malpractice. But a greater trend is to shape modern medical science
so that there is more and more “need” for investigations, hospitalization and surgery.” Sir, madam,
the second is more than mere “malpractice”, it is paranoia on your part and megalomania on the
part of the modern medical scientists engaged in this endeavor, if any are so involved. Both are
pathological conditions and call for therapy.
“But since no value is too high for human life, the ability to price is limitless. It is limited only by the
ability of the consumer to pay.” “Rhetoric” is defined by my Webster’s College Dictionary as
‘language skillfully used’. It goes on to also define it as the ‘undue use of exaggerated language;
bombast.’ I submit that along with the evils of globalization we have also been given to learn the
skills of shopping. A fool and his/her money will always part ways soon. We do not debate the
actions of fools. Corporate hospitals target the well-to-do as customers; they got that way by being
savvy about money matters. They pay for quality.
The economic risk of providing comprehensive services to a potentially large and eventually
enrolled population will have to be managed by clinical integration and disease management. This
is the reengineering of patient care. The design opportunity in this is not simply to make
reengineered care clinically efficient, but to focus on the patient care experience and on the
processes of achieving greater efficiency through improved engineering and facility design. The
mantra is patient-focused care, not about providing spectacles by charging separately for the
frame and each of the lenses.
As the kids nowadays say, “get real…”