India s Healthcare Hurdles. Volume 9 Issue 2 RS 250

Transcription

1 IN THIS ISSUE : STEPHEN M SAMMUT AND LAWTON R BURNS CALL FOR INNOVATIVE SOLUTIONS TO MEET INDIA'S HEALTHCARE CHALLENGES DR DEVI SHETTY ON HIS SUCCESSFUL MODEL OF HEALTH CITIES NANDINI RAJAGOPALAN DISCUSSES THE MERITS OF HIRING AN OUTSIDER CEO Volume 9 Issue 2 RS 250 India s Healhcare Hurdles

2 from he edior s desk Dear Reader, These are exciing imes for us a ISB no only are we celebraing he enh year of he school, we are also vigorously preparing for he sar of our new campus in Mohali, Punjab in April Apar from offering he flagship Pos Graduae Programme in Managemen, he Mohali campus will have specialis insiues in areas criical o India s developmen - Healhcare, Infrasrucure, Manufacuring and Public Policy. Over he nex few issues, we will highligh each of hese areas in he ISBInsigh, beginning wih his issue on Healhcare. I hank Professors Sephen M Sammu and Lawon R Burns of The Wharon School, our academic parner for he Max Insiue for Healhcare Managemen in Mohali, for kindly collaboraing wih us on his issue. India needs a healhcare sysem ha can mee he demands of over a billion people, mos of whom are unable o bear he burden of healhcare coss each year 39 million people are pushed ino povery because of heir inabiliy o mee healhcare coss. The challenges are garganuan, as our cover sories poin ou: India leads he world in erms of maernal deahs; here is a dearh of qualified medical professionals in rural areas; healh insurance covers only abou a fifh of he populaion while unorganised privae secor accouns for almos 80% of oupaien healhcare. Bu even in hese bleak circumsances, some medical enrepreneurs have crafed soluions wihin heir limied resources Dr Devi Shey is one such person, and we presen an inerview wih him in his issue. Our feaure sories demysify some long-held beliefs: Ousider CEOs migh no be he superheroes ha will save your firm, and blogging, even if i s someimes negaive, can help your company. I hope you find his issue ineresing and insighful. Do send me your feedback a [email protected]. I look forward o hearing from you. Sriram Gopalakrishnan

3 Cover Sory Meeing he Challenges of Healhcare Needs in India: Pahs o Innovaion BY STEPHEN M SAMMUT AND LAWTON R BURNS How does he qualiy and availabiliy of healhcare services keep pace wih a vasly improving sandard of living in a rapidly developing counry? And o wha exen can access o ha qualiy care be available o all socioeconomic levels? These quesions have a special relevance o India because progress in healhcare availabiliy or he lack of i will accelerae or deer growh as well as deermine he fuure of poliical leaders.1 This aricle explores he paricular challenges o medical professionals in he indusry of wellness and healing, and o naional policy-makers in meeing he needs of he growing Indian populaion. Wha are he key goals of healhcare in every counry? We can summarise hem as follows: Improved qualiy of care and populaion healh as measured by life expecancy and oher measures of wellness. Cos conainmen and pooled risk-sharing by he populaion o allow fi nancial access o care as well as avoid caasrophic ruin. Provide access o care in an equiable manner for all ciizens. I is no our purpose here o grade India on is performance on hese goals. Many sudies have addressed hese quaniaively and qualiaively.2,3,4 The paricular challenges should be invenoried so ha heir impac may be assessed, he inervenions described, and innovaions prescribed. The Srucure of he Indian Healhcare Sysem The public side of he Indian healhcare sysem has differen roles for he naional governmen and individual saes. The Governmen of India addresses healh policies, regulaory maers and disease conrol. The saes address healhcare delivery, fi nancing, and he raining of personnel. The naional Minisry of Healh has several funcional deparmens: Healh Services, Family Welfare, Healh Research, and Tradiional Medical Sysems. The sae minisries ypically have deparmens of Medical Educaion and, similar o he naional minisry, Healh Services and Family Welfare.5 Despie his large infrasrucure and aenion o need, he public secor acually provides only abou 20% of acual care services. The ISB INSIGHT 5

4 Cover Sory balance of care is provided by privae hospials and praciioners. Challenges in Healhcare The minisries mus address several prevailing challenges, as described in a recen series on India in The Lance: Coninuing burden of infecious diseases in healh. Reproducive and child healh and nuriion Chronic diseases and injuries Universal access o care and healh equiy Healhcare human resources Healhcare fi nance The series offers one of he mos coheren and horough analyses of hese facors and provides a provocaive framework for his aricle. The six opics are absraced and for each, we will describe he siuaion, an innovaive inervenion, and he business and organisaional challenges ha hey represen. Business and Organisaional Challenges: The formaion of an inegraed naional/sae public healh sysem represens a new caegory of coss for he governmen. Hisorically, in oher counries, public healh policies and laws have had o fi nd a balance wih personal privacy and civil liberies. Is he iming righ for India o underake such effors? Wha is he role of a business school in his ransformaion? Reproducive and child healh, and nuriion The Siuaion: India has he world s greaes burden of maernal, newborn and childhood deahs. India also has he greaes number of undernourished children.7 The pace of improvemen has been slow and falls shor. Among he reasons is ha coverage for prioriy inervenions remains insuffi cien, and he conen and qualiy of exising programmes is subopimum, furher complicaed by unaccepable inequiies is he conclusion drawn by Paul e al.8 Innovaive Inervenion: Paul e al cie oher reasons bu also provide a soluion. They offer ha he healh Coninuing burden of infecious diseases sysem has o be rehough wih decenralised planning 6 The Siuaion: John e al poin ou ha several in disrics, effecive service delivery in communiies infecious diseases and vaccine-prevenable childhood and healh faciliies, a reasoned approach o demanddiseases sill conribue 30% of he disease burden side fi nancing, a susained programme o change in India as measured in disabiliy adjused life years household behaviours, and creaion of cenres of los. The economic impac of his is enormous. The excellence for healh and nuriion policy research. consequence is also an overloaded public hospial care Business and Organisaional Challenges: Proposals nework ha mus address he primary care needs of for change and improvemen mus be abeed by inpu infeced paiens. from policy-makers and he privae secor. There are Innovaive Inervenion: The radiional approach specifi c challenges ha academics may consider in of a naional governmen inervenion programme order o have equiable and susained improvemens. for each disease is no likely o be effecive or cos- These cu across he enire specrum of a major effi cien according o John e al. They recommend he business school curriculum. creaion of a funcional public healh infrasrucure ha is shared beween cenral and sae governmens, Chronic diseases and injuries wih professional leadership and a formally rained The Siuaion: According o Pael e al, Chronic cadre of personnel who manage an inegraed conrol diseases and injuries are he leading causes of deah mechanism of diseases in disrics for infecious and and disabiliy in India and here will be pronounced non-infecious diseases and injury. increases in heir conribuion o he burden of disease 6 ISB INSIGHT

5 Cover Sory during he nex 25 years. Mos chronic diseases are equally prevalen in poor and rural populaions, and ofen occur ogeher... Much of he care for chronic diseases and injuries is provided in he privae secor and can be very expensive... India has already passed he early sages of a chronic disease and injury epidemic; in view of he implicaion for fuure disease burden and he demographic ransiion ha is in progress in India, he rae a which effecive prevenion and conrol is implemened should be subsanially increased. 9 Innovaive Inervenions: In he Wes, more han wohirds of all healhcare coss are consumed by paiens wih fi ve or more concurren chronic diseases. In he Wes, public or privae insurance sysems dominae healhcare fi nance. Beyond inervenions for poenially caasrophic fi nancial impac on paiens and heir families, are he inervenions for prevenion and managemen of risk facors. For example, cardiovascular diseases presen wih angible risk facors such as hyperension, high body-mass index, high blood glucose and choleserol, and obacco use. Business and Organisaional Challenge: The principal challenge wih respec o chronic disease and injury is o provide care a a cos ha will no bankrup he naional economy or households. A key o his problem is avoiding onse of he diseases or limiing heir severiy. The role of businesses in his dimension of inervenion is one of cooperaion and collaboraion, ha is o say, recepiveness o behaving in accordance wih he public good. The medicinal inervenions can leverage he commanding posiion ha he Indian generic pharmaceuical indusry has esablished. Universal access o care and healh equiy The Siuaion: Balarajan e al repor ha inequaliies are relaed o socioeconomic saus, geography, and gender and are compounded by high ou-of-pocke expendiures, wih more han hree-quarers of he increasing fi nancial burden of healhcare being me by households. Healhcare expendiures exacerbae povery, wih abou 39 million people falling ino povery every year as a resul of such expendiures. Balarajan idenifi es key challenges for he achievemen of equiy in service provision, and equiy in fi nancing and fi nancial risk proecion. These include an imbalance in resource allocaion, inadequae physical access o high qualiy healh services and human resources for healh, high ou-of-pocke healh expendiures, infl aion in healh spending, and behavioural facors ha affec he demand for appropriae healhcare. 10 Innovaive Inervenions: There are principles of healh equiy ha Balarajan promoes: Equiy merics, as applied o daa for healh and healh sysems, needs o be inegraed ino all healh sysem policies and implemenaion sraegies a every sage of he reform process. An equiy-focused approach is needed o gaher, use, and apply daa for healh oucomes and processes of healhcare, and during monioring and assessmen of healh sysems performance. Business and Organisaional Challenge: Any daadriven approach and analyic sysem mus be driven by sysems analysis and sofware developmen underaken by he privae secor. The ques for healh equiy presens an ideal opporuniy for a series of public-privae parnerships direced a definiion, daa capure and analysis, and ransfer and implemenaion of he conclusions ino pracice. As much as 80% of Indian healhcare is privaely provided, and ha care is increasingly funded by insurance programmes; he mechanism for a fully inegraed sysem is falling ino place. Healhcare human resources The Siuaion: India has, according o Rao, a severe shorage of qualifi ed healh workers and he workforce is concenraed in urban areas. Many Indians, especially hose living in rural areas, receive ISB INSIGHT

6 Cover Sory Sephen M Sammu is Senior Fellow a Deparmen of Healh Care Managemen a The Wharon School, Universiy of Pennsylvania Lawon R Burns is Professor and Chair a Deparmen of Healh Care Managemen a The Wharon School, Universiy of Pennsylvania care from unqualified providers. The oumigraion of qualified physicians and nurses is subsanial. The resources o rain nurses are sill inadequae. The rapid privaisaion of medical and nursing educaion has implicaions for is qualiy and governance. Such issues are a resul of underinvesmen in and poor governance of he healh secor wo issues ha he governmen urgenly needs o address. 11 Innovaive Inervenions: There are numerous inervenions and Rao highlighs seps aken in Tamil Nadu. Among hem, new posiions were esablished in primary healhcare seings. Nurses, in paricular, were expanded from one o hree. The nurses are se up wih a eam of wo medical officers o provide round-he-clock service. Tamil Nadu has also made provision for educaion of physicians and nurses in he public secor. Incenives and policies are in place o arac and reain personnel. In reurn for educaion, professionals have hree years of mandaory rural service. This sraegy can be duplicaed in oher saes. Business and Organisaional Challenge: Service in small ciies, remoe villages and rural seings remains an unme need. I is no necessarily a funcion of income; physicians and nurses prefer o develop heir knowledge base and pracice wihin a communiy of providers. Neverheless, packages of incenives, boh financial and less angible, mus be developed and suppored, perhaps in concer wih he developmen of rural healh insurance programmes. Healhcare finance The Siuaion: Kumar e al observed ha India s healh financing sysem is a cause of and exacerbaing facor in he challenges of healh inequiy, inadequae availabiliy and reach, unequal access, and poor qualiy and cosly healh care services. Low per-person spending on healh and insufficien public expendiure resul in one of he highes proporions of privae ou-ofpocke expenses in he world. Financial proecion agains medical expendiures is far from universal wih only 10% of he populaion having medical insurance. (See he aricle in his issue on healhcare access.) The Governmen of India has made a commimen o increase public spending on healh from less han 1% o 3% of gross domesic produc during he nex few years. 12 Innovaive Inervenions: Kumar e al ouline six policy responses: Ensure achievemen of governmen s commimen o increase public spending on healh from less han 1% o 3% of GDP. Improve qualiy, performance efficiency and accounabiliy of public and privae healh sysems. Inroduce policy and legislaive changes o conain he rising coss of medical care and drugs. Increase availabiliy of healh services hrough direc expansion of public healh services. Increase insurance and risk pooling o include financial proecion. Inroduce a predominanly ax-paid universal medical insurance plan ha offers essenial coverage o all ciizens. Business and Organisaional Challenge: The privae secor should have an expanding role in he provision of care. The Lance Series is silen on he role of he privae hospial sysems, such as MaxHealhcare, and he role hey play for middle-class access and he provision hey make for providing for he less forunae. Moreover, he role of such effors a he Aravind Eye Care Sysem, Dr Devi Shey s Narayana Hrudayalaya Cardiac Cenre (See he inerview in his issue wih Dr Shey), and he Vaasalya Hospial 8 ISB INSIGHT

7 Cover Sory sysem sraegy for delivering care in underserved areas all offer valuable and reproducible sraegies. The challenge in he expansion and implemenaion encompasses all he above issues as well as meeing capial needs of he organisaions. Conclusion This brief aricle may overwhelm readers unfamiliar wih Indian healhcare, wih he magniude of he problems and heir complexiy. Tha is an appropriae response, bu he problems are addressable a he level of he enerprise and are solvable wih innovaive hinking. The posiions of many of he auhors cied wihin do seem o favour he role of governmens, naional and sae, as he eniies wih primary responsibiliy. This may be rue, bu he expansion of he Indian healhcare sysem will likely remain a hybrid of privae providers and public providers. Convergence of hese wo worlds presens he challenge of all challenges. Driving his convergence and he eaching of he bes principles of healhcare managemen will be prevailing hemes in he curriculum of he new major in Healhcare Managemen o be launched a ISB s new Mohali Campus. This aricle is an adapaion of he inroducory chaper of he book based upon a course eniled Innovaion and he Healhcare Indusry conduced by Professor Burns a he Indian School of Business (ISB) in January 2010 and 2011, o combined classes of ISB and Wharon sudens. 1 Bloom, D., D Caning and J. Sevilla. The Effec of Healh on Economic Growh World Developmen, 2004, 32: Mahal A., B. Debray and L. Bandari, eds. India Healh Repor Indicus Analyics. Published by BS Books, New Delhi ( 3 Cenral Bureau of Healh Inelligence (CBHI). Naional Healh Profile New Delhi: Governmen of India, Direcor General of Healh Services, Minisry of Healh and Family Welfare. 4 Horon, R., P. Das. Indian healh: he pah from crisis o progress. The Lance. January 15, : Governmen of India. Minisry of Healh and Family Welfare. hp:// 6 John, T.J., L. Dandona, e al. Coninuing challenge of infecious diseases in India. The Lance. January 22, : Hogan, MC, KJ Foreman, e al. Maernal moraliy for 181 counries, The Lance, : Paul, V.K., H. S. Sachdev, D. Mavalankar, e al. Reproducive healh and child healh and nuriion in India". The Lance. January 22, : Pael, V., S. Chaerji, D. Chisholm., e al. Chronic diseases and injuries in India. The Lance. January 22, : Balarajan, Y., S. Selvaraj, S.V. Subramanian. Healhcare and equiy in India. The Lance. January 22, : Rao, M., K.D. Rao, e al. Human resources for healh in India. The Lance. January 22, : Kumar, A.K.S., L. Chen, e al. Financing healhcare for all. The Lance. January 22, : ISB INSIGHT 9