CHENNAI : If healthcare has recently moved to centre-stage, it is because it has become a political priority in the setting of the upcoming elections. The magnitude of ill-health in India has become too severe to be ignored. Every political party is keen to address this issue as life-saving and potentially, vote-winning. One just needs to read WHO’s ‘Global Burden of Disease (GBD) India 2017’ to get a glimpse of the falling standards of healthcare in India.
What is striking is the strong presence of a dual disease burden — objective evidence of sub-optimal health parameters of the Indian population, and the emergence of new public health concerns. The GBD report must provoke the stakeholders of health to sincerely appraise the situation scientifically more than politically, to avoid a national crisis, which it may already be. The Ayushman Bharat is certainly commendable as a courageous initiative to address health as a national priority, but its long-term financial sustainability is questionable.
The health administration has not addressed the evolving changes in public behaviour as well as other paradigm shifts arising out of epidemiological transitions and emerging technology.The current healthcare scenario in India is a complex matrix of issues arising from changes that seem inevitable. Some of them spin off from global trends while others are more India-specific. Changes in the behaviour of all three stakeholder groups — consumer (patient), provider (hospitals, pharmaceuticals) and regulator (government) are of great relevance. Conventional strategies to healthcare delivery are proving to be grossly insufficient as the authentic GBD narrative on India’s health from WHO shows.
Illness presentation
The most crowded and ‘Code-Redded’ services in any big hospital would be emergency care, coronary care units, medical intensive care and trauma care. There is a growing demand-supply mismatch in this segment. The current lifestyle of people impacted by prolific travel, unhealthy diet, stress, industrialisation, pollution and cardiovascular risk factors has created more emergencies in the form of accidents, respiratory emergencies, heart attacks and strokes. The number is too large to cope with considering the existing infrastructure.
The plethora of ambulances criss-crossing the crowded Indian roads bear testimony to this. Future hospital infrastructure and manpower planning must aim for at least 25% to 30% of beds for emergencies. On the contrary, there is a change in the reverse direction that cannot be ignored. Chronic care beds in many big private hospitals remain empty because of the escalating costs.
Patient behaviour
With healthcare costs still ‘out of pocket’, patients have are discouraged to seek hospital-based care. Rising cost is a major disincentive as was seen during demonetisation when patients cancelled their surgeries and private consultations due to lack of hard cash. There are two other attitude changes that have become obvious. One is the shift towards alternative medicine marketed aggressively by the non-allopathic community.
There is a small but significant decline in seeking allopathic therapy for non-urgent problems. With the mindset of the Indian society veering towards ‘AYUSH’, allopathic healthcare is likely to face some competition. The second is the growing trust-deficit between the public and physicians. Negative propaganda against doctors and hospitals in the social media and half-baked medical information on the internet reinforces the trust deficit.
Epidemiological profile
India suffers from ‘dual disease burden’ with a plateaued but unconquered chunk of communicable diseases and a rapidly growing share of non-communicable diseases (NCD). The Global Burden of Disease Report demonstrates the unique duality that India faces. The available public and primary health system is too weak to handle the ever increasing NCD load, currently clocking 60% of the total disease burden. The existing hospital ecosystem is unable to bridge the demand supply mismatch in terms of infrastructure, manpower, resources and accessibility.
On the other side, cases of tuberculosis and malaria continue to ride episodically to remind us that the battle is still raging. Primary care strategies such as diet regulation, school health awareness, diabetes, hypertension and lifestyle interventions are not yet in the centre of the government’s attention.
Regulatory controls
Regulation of pricing of drugs and devices has been a welcome move to cap the profit margins of the provider. However, this measure has not benefitted the patients. What needs to be controlled is the trend of over investigation, over scanning, over diagnosis and over procedures by tighter clinical audits. The penetration of health insurance is still a drop in the ocean compared to the need for total coverage.
Practice profile
Technology-driven medicine is steadily increasing its share in the healthcare space. Tele-medicine, device-based monitoring and artificial intelligence have already burst on to the health platform, setting the stage for disruption of traditional health solutions. While it remains too premature to predict the contributions of artificial intelligence to good ethical practice, the immediate future of medicine seems invaded by the potential benefits of technology. Undoubtedly, the marriage of technology to medicine is going to be an expensive proposition.The author of the article is Dr Sunil Chandy, professor of Cardiology and former director, CMC Vellore