The Good News and (And Not So Good News) About Preventive Healthcare in India
Is preventive healthcare in India still a work in progress? An HE report.
What is the recipe for longevity, good health and happiness? Does it involve ingredients like healthy food, movement as well as restructuring healthcare system? Is it possible to grow old without conditions like diabetes, cancer, obesity or heart problems? Well, it definitely requires a set of preventive interventions.
Just look at these numbers. In India, out-of-pocket expenditure is as high as 62%. Russians spend only 40 % from their pockets; the Chinese 30%, Brazilians 25% and South Africans as low as 6.5%. Take colonoscopy. The procedure recommended for people above 50s is rarely part of healthcare packages offered by hospitals or covered by insurance policies. A majority might skip the pricy screening test and go for cheaper alternatives like a stool test.
Primary Care = Preventive Care?
It is tough to come up with a staple of affordable preventive care tests in India, where the government doesn't spend much on healthcare. Dr. Devashish Saini, the founder of Ross Clinics, points out that there is a huge healthcare need in India, regarding availability, flexibility and the quality of care. “Eighty percent of the healthcare problems can be taken care of at a primary care clinic,” says Saini, an alumnus of AIIMS. Saini set up Ross clinic to provide primary care, that is affordable and accessible to the communities to improve their health.
Ross has 15 clinics in its network; four of them are full-fledged clinics with full-time doctors and the whole set of related services, as well as satellite clinics. The business model focuses on running high-volume, low-cost primary care centres that will achieve efficiency through economies of scale.
According to Saini, millennials are more conscious about their fitness levels, healthy eating as well as lifestyle diseases. “People are more aware of conditions like NCDs today. However, they would require a mentor to navigate the maze of information. Another challenge is that Indian doctors are not taught how to bring about behavioural change in their patients. The curriculum focuses more on curative aspects rather than prevention."
While Saini might be right about the population in metros, it is true that majority of patients in India cannot afford a Healthifyme or MyFitnessPal or a Lybrate. Even though government schemes focus on NCDs, more often than not, conditions like infant mortality get more attention from policymakers. Further, nutrition is also another major challenge.
A good prevention scheme identifies members of the community who are vulnerable to various conditions and conducts regular screening tests. However, this is a more expensive model and will cost 20 times more than what the government is spending on health.
"Most ambulance visits to a hospital are a case of missed preventive care," says Vikram Kumar is the CEO of Multiplier, a leading healthcare analytics solutions company that uses AI to drive personalised and predictive healthcare marketing. “More than 50% patients showing up in ambulances are past patients, the number of whom are delaying clinician visits, could have been detected early through better preventive care," he explains.
Multiplier uses AI to identify candidates for early screening for 5 of the top 10 hospitals in India, which resulted in 30,000 screenings last year. AI has brought in new technology to identify candidates for testing. Just like Amazon predicts your purchase with the help of AI, the same way it is possible to predict who is the right candidate and what combination of tests they will buy. Kumar points out that tertiary care hospitals have a passive interest where they switch on and switch off on health checks as being a key initiative since the effectiveness of such efforts were limited. "Revenue from health checkup initiatives is typically less than 2% of the revenue of hospital hence is not an interest," he adds.
So is it all just a waste of money?
In the current system, many experts point out that doctors make more money when patients are unhealthy. They do earn more when more procedures and drugs are prescribed.
Kamal Mahwar, the author of The Ethical Doctor, has a different take on the whole issue. He notes that healthcare delivery can be divided mainly into preventive and therapeutic.
“Prevention of the disease can take many forms and involves almost every aspect of human endeavour. It includes efforts like improving air quality, access to clean water, sanitation facilities, reasonable habitat, and even social and economic issues. The more direct preventive measures like vaccination programmes, health education and other such measures fall in the purview of public health which is delivered by the state.
“So, preventive healthcare in that sense is not really in the ambit of individual doctors. It is the responsibility of the state and society. Doctors who specialise in public health can guide the process. However, many methods of prevention of diseases like more education, less pollution and a healthier lifestyle are commonsensical, and we don’t even need a doctor to know that.
“Generally, the health of a society is an output of its social, economic, and educational attainment. It is too big a task to be left to individual practising doctors alone who don’t even have the desired means or the training to deliver preventive healthcare,” he adds.
So what can be done? You might want to listen to listen to CEO of Medlife, Tushar Kumar. “In 2018, India’s healthcare expenditure was just a little over 1% of its GDP. Further, over 90% of the healthcare budget was spent on the treatment of diseases and patient care. The Indian healthcare system is reactive. Patients don’t act proactively and often visit a hospital only when the disease has reached an advanced stage. This can be attributed to lack of awareness about diseases, care, and services available. Even the health insurance provided by the state and private companies focus on the treatment of diseases after they have occurred instead of preventing them in the first place. Non-communicable diseases which formed less than 30% of the total disease burden in Indian in 1990 is slated to grow up to 57% by the year 2020. Preventive healthcare, therefore, must be the backbone upon which the healthcare delivery system of India should be built,” says Kumar.
How can we address this issue? As Kumar explains, the private healthcare industry in India is in a unique position to address this issue. The private medical sector remains the primary source of healthcare delivery for 65-70% of households in India, relying mostly on out-of-pocket expenditure as the insurance penetration is low. The need of the hour is to unite the private healthcare industry with a singular aim to improve the healthcare status of the country. It should move beyond the linear growth such as adding new hospital beds and physicians. Instead, focus on leveraging technology to provide preventive healthcare to the masses. The challenge of identifying patients at risk of developing a condition, deteriorating due to lifestyle, environmental, genomic or other factors can be addressed by a combination of increasing awareness by education, regular screening tests, and regular doctor’s visit. Various ways in which technology can be helpful here are by developing an integrated, interoperable electronic health record system, leverage telemedicine to bridge the geographical divide, and develop Internet of thing and AI to address the preventive aspect of medicine.
Dr Monica Goel, a consultant physician at PD Hinduja Hospital, has a different view though. "There are only about 5-10% of people who are insured in India. Hence, they find taking these tests costly. We need a 360-degree approach to preventive healthcare. Even though there are many outreach programs started by the government, there are so many deaths during childbirth which should not be the case in the 21st century," she says.
Collaboration is the Need of the hour
What has P.D. Hinduja done? "We have tie-ups with corporates. So then it’s like a forced annual checkup for the company employees, there is also a pre-employment checkup, there is a health card for employees of all statures not just for the senior employees. All this is done so that the person doesn’t feel heavy on the pockets. During the checkup, there are so many incidental findings that come up; we have had detection of simple things like anaemia, breast cancer, diabetes. All these happen mostly due to job stress and physical inactivity," she concludes.