Dileep Mavalankar's Pills for the Health Sector Ills
Healthcare Executive sits down with Prof. Dileep Mavalankar to discuss the future of Indian healthcare and how to get it back in the growth groove.
Prof. Dileep Mavalankar is a firm believer in the Indian dream. That is possibly why this doctor is at the forefront of Indian Institute of Public Health Gandhinagar as its Director since 2012. He obtained an MBBS and MD in Preventive and Social Medicine from Gujarat University in Ahmedabad, and MPH and Dr P.H from the Johns Hopkins School of Hygiene and Public Health, USA.
His work experience includes faculty and research positions in NHL Municipal Medical College, Ahmedabad, National Institute of Health in Bethesda, USA, Indian Institute of Management in Ahmedabad, India and Mailman School of Public Health, Columbia University, NY, USA.
Born in a family of health experts, he always knew that he would take his fathers legacy forward and work in the health sector one day. "During our time, there were minimal career options like medicine and engineering. My father was a doctor and used to take me to hospitals; that's how I got interested in medicine. I had an excellent teacher in public health and preventive medicine, and he inspired me to specialise in public health," recalls Mavalankar, whose family originally hails from Maharashtra.
Keep Calm and Carry On
Today coronavirus and a slow economy have dented investor confidence. And many experts warn of more troublesome days and traditionalistic approach in spending. But Mavalankar says that Indian healthcare sector should be more optimistic. "The public hospitals in India are much better today due to government initiatives like the National Rural Health Mission, which is currently called the National Health Mission, from 2005 onwards. The condition of hospitals in rural areas has enhanced. Indeed, a rural health centre is nowhere close to national or international standards. Investment needs to go up. But it is also true that we have achieved a lot like more human resources, equipment, technical infrastructure improvement over the last decade. Government insurance schemes like Rashtriya Swasthya Bima Yojana and Ayushman Bharat has empowered the Indian patient. However, we still don't have outpatient coverage. The doctor-patient ratio in rural India is 1:30,000, in the UK, there is one GP for 2000 people. The ANM designation was created after the Second World War, and we recently changed it to a community health officer. We are now in some sense improving the quality of the health worker in a rural area," explains Mavalankar.
But are our policymakers proceeding in the right direction? "Yes", says Mavalankar. "But they should move at a much faster pace and increase the funding at least by double in the next two-three years. They should also focus more on primary care than focusing only on setting up more medical colleges," he adds. He also points out that the government should focus more on efficiency.
Demand for Chronic Care Management Outpaces Acute Care Services
PMJAY is infusing much-needed lease of life to the healthcare sector. But Mavalankar says that the focus should also be on out of pocket expenditure of patients.
"If the government provides free medicine to patients, that will be extremely useful. The most crucial element of Out of Pocket Expenditure of outpatient cost is medicines. The number of people who require hospitalisation out of 100 might be only one or two. For example, if you get conditions like dental caries requires private checkups and expensive," he adds.
So does health mean only hospitals or doctors? "It also depends on other factors like water, sanitation, clean air, nutrition and mental health. We don't have local bodies, and state governments often don't understand the value of environmental health. Many countries have environmental protection agencies. We have a Pollution Control Board. Public health is a multi-sectoral and multi-disciplinary subject; it is not a medical subject. We need public health schools, where there is a collaboration between different disciplines. Take sound pollution, for instance, and it's a physics-related issue. It would be best if you had multi-disciplinary teams working on this issue. We need statisticians and epidemiologists to solve public health issues. Public Health is a misunderstood and politically unpopular subject. First, you don't take care of people; therefore, they develop cancer. Cancer is not easily treatable at hospitals; then, you create cancer hospitals or AIIMS. That's a costly path to follow for India," he explains.
What is the fix for India's healthcare policymaking woes? He points out that India doesn't have many patient advocacy groups. "For HIV, you have influential patient groups who put pressure to create policies. However, for other diseases, we don't have many community groups. For example, there are no patient groups for cancer. Why are we not having national-level screening for different forms of cancer? Government responds to pressure and praise. For chronic diseases, we don't have political advocacy skills," he says.
Universal Healthcare
Further, Universal healthcare is imminent, according to Mavalankar. "Ayushman Bharat has improved access to the bottom 40 per cent. The hope is that the government would gradually include other sections of society. Authorities should also include the outpatient cost into the ambit of PMJAY. They should create pilot projects and see outpatient costs should be covered. Vouchers for patients with chronic illness and patients can use these vouchers for outpatient treatment. PPP models can be explored for outpatient care. Otherwise, government hospitals will be flooded. You need multiple NGO hospitals to deliver outpatient care."
He also adds that today air travellers don't discriminate between an Air India or a private carrier. "The services are comparable. We need to create a large number of government hospitals giving high-quality care. People don't prefer government hospitals because of the lack of infection control, overcrowding and they being understaffed".
Dynamic Pricing and Monitoring System is Key
He also reckons that there will bad sheep in any system. "The procedure rates must be based on market rates to avoid any malpractice. We need national level or state level commission to fix rates, or else good players won't be part of the scheme," he adds.
He notes that in rural areas, you have a sub-health centre. "In urban areas, there is no urban health centre to cater to the population. At Ahmadabad, for one or two lakh population, we have one urban health centre with one doctor. The government can set up ten sub-health centres with one doctor or a nurse practitioner. In urban areas, we should swiftly adopt the Mohalla clinic model. It will reduce the number of patients in medical colleges. In western countries, there are community hospitals, so that patient does have to travel for care."
Reinventing Healthcare
But, how to bridge the gap between poor-performing states and well-functioning states? According to Mavalankar, states need money as well as skilled human resources. "State government also need to take the initiative because the centre can't do everything. Even retired public health officials can be roped to work in poor-performing states."
The public health expert points out that our health system should be so good that even Mukesh Ambani, should be willing to go to a hospital empanelled within the PMJAY scheme. "That is Universal Care. If you have a road built, everyone should be able to use it. That is a developed country. It is not going to cost a lot if you do it in phases," he explains.
Lastly, what does he think that the future of healthcare encompasses? "In the next decade, much new machines and technology would enter the healthcare sector. Teleconsultation will become the first stage of care, and a local pharmacy will deliver your medicine. The focus will be more on the quality of life of the patient, than just merely saving them. Mental health should also be covered by health insurance in the future," he concludes.