Postmortem of healthcare delivery space in India – Past, present and post-COVID future

“We can’t manage what we can’t measure” – this essence of Peter Drucker is rightly applicable to Indian healthcare delivery space as well. With this context, let us decipher the Indian healthcare delivery space.

Past (pre-independence, post-independence and up to 1980) – Struggles for basics
Ancient Vedic period gave tremendous knowledge on Indian medicine through Vaidyas and witnessed the advent of celebrated surgeons Sushruta and Acharya Charak – the court Physician of King Kanishka. Vedic literature like Yajur Veda truly believed that the world should be free from diseases and everybody should have a healthy mind. The Buddhist period considered taking care of the sick as a holy act and monks and monasteries contributed significantly to treating and caring for the sick along with practicing medicine. Muslim attackers brought with them Hakims and their Unani system has had an impact on practices of medicine in India in isolation and in combination with Ayurveda. The 15th century saw the spread of Christianity and European influence on India. The Portuguese founded the Royal Hospital in Goa and that marked the start of modern medicine and its practices in India. A significant impact British India had on healthcare was the starting of modern medical schools in Kolkata and Chennai and establishment of Divisional and Sub-Divisional Dispensaries. Around 1885, there were 1250 hospitals and dispensaries in British India.

Progress continued and on the eve of Independence, India had 7400 hospitals and dispensaries, 47,000 doctors, 7000 nurses, 47 medical schools and colleges, with 113,000 beds, i.e., a bed-population ratio of 0.24 per 1000 population. The Bhore Committee, formed in 1943 submitted its report in 1947 recommended upgrading medical care and setting up primary health centers in villages, secondary health centers at Taluka level and district hospitals at district headquarters in the form of tertiary health centers. Irrespective of affordability, the Committee aimed to have 1.3 beds per 1000 population in 10 years and 5.6 beds in 25 years. Promotive, preventive, and integrated public health was its sacred recommendation. The Planning Commission setup in the 1950s, however, neglected health and allocated tiny sums and low priority to healthcare. Democratic decentralization practically shifted responsibilities of healthcare on states and on its people. A study group on hospitals setup by the Planning Commission in 1966 revealed that recommendations of various committees like Bhore Committee, Mudaliar Committee, Kartar Singh Committee, etc., were not implemented and visible gaps of hospital administration both on clinical and non-clinical domains were highlighted.

Present (1980s to 2020) – Compartment, chemistry of chaos and convenience
The first private corporate hospital in India was started in early 1980s and there is no looking back after it. Private hospitals have flourished and have become the backbone of advanced medical care, especially in major urban Tier-I and Tier-II cities. This period has stood apart as three National Health Policies (NHPs) have been formulated in 1983, 2002, and 2017 respectively. NHP 1983 aimed to achieve Health for All by 2000, to have a comprehensive network of primary health centers across India, to prepare skillful cadres of healthcare workers, and to have a strong referral network from bottom to up with primary, secondary, and tertiary healthcare providers. Private sector and its participation became significant. NHP 1983 failed due to lack of economic development at grassroot and growing inequalities between the rich and the poor. NHP 2002 aimed to have strong primary healthcare and public health, converging all healthcare programs under one umbrella, and larger role of NGOs and private sector. Unwanted highlight of this period is duplication of specialty and super-specialty service providers in urban India at one extreme and on the other extreme there is complete lack of availability of healthcare services at grassroot level. Public healthcare providers are not so efficient, and are unable to stay true to the referral network of the health service system. Trust hospitals are struggling for financial viability and finding it difficult to survive amidst the juggernaut of private corporate hospital chains. Professional hospital administration is still in its nascent stage in Tier-II and Tier-III cities of India.

NHP 2017 identifies priority areas within the health system and focuses on leveraging Ayushman Bharat Scheme, National Digital Health Mission, and structured reforms in healthcare. Ayushman Bharat Yojna (PMJAY) breaks away from the disease-specific approach and proves to be the single most important factor in providing access and availability of comprehensive healthcare services as a whole to more than 10 crore families who are at the bottom of the pyramid in India. Two key objectives of PMJAY are to develop 1.5 lakh health and wellness centers across India and to provide cashless benefit for any healthcare need of individual and families up to 5 lakh rupees near to their place.

Future (post-COVID 2020 onwards) – 360’ transformative era
COVID-19 Pandemic proved once again that India needs to have a futuristic action plan in place to be in the league of developed nations as the health of its population directly impacts economic growth and development. One of the long-term impacts COVID-19 will have is the political focus on healthcare and bringing health at the center stage in all debates and discussions. Policy makers now very well understand that healthcare delivery space needs to be strengthened by more and more budgetary allocations and developing integrated holistic frameworks around it. COVID-19 has far-reaching consequences when it comes to building blocks in villages and Tier-III and Tier-IV cities across India. Following aspects will have an impact in the way Indian healthcare delivery space will fan out in the next 10 years.

• Primary health and wellness centers will have local flavor and integrated approach centered around populations they have around them, and will become pivotal in delivering last-mile benefits to the people. These fundamental blocks will be holistic and more integrated and will be more active in promotive, preventive, and primary care delivery. Incentive-linked models will be developed through the advent of NDHM and real-time interventions will take place around it.
• Grassroot centers will see more PPP models evolving and will be flexible in its approach in terms of capacity building and scalability and will have horizontal integration with allied and other service delivery to the people.
• Tier-III and Tier-IV cities will witness rapid rise of secondary and tertiary care setups and will cater to around 50 percent of healthcare needs of the country. Economic and developmental growth in these segments will witness transformation in terms of the care delivery space planning by public and private sector in these zones. Demand will push the supply side in healthcare delivery space. Healthcare delivery space will offer attractive employment opportunities for the millennials. Better living standards will be rated with the prism of availability and accessibility of quality healthcare services in Tier-II and Tier-IV cities. Competitive market will keep up with the innovation and will see steady investment in these zones by all stakeholders. Healthcare hubs-and-spokes models will take fresh approach, and various models of care delivery will witness rapid success.
• Tier-I and Tier-II cities will witness efficient care management and will become part of a larger network of integrated care delivery systems in the country. Medical tourism will become a major revenue source in these cities. McDonaldization of healthcare delivery will be a realistic phenomenon. Hospitals will be seen as neighborhood hospitals and to retain and have a loyal patient base, a lot of emphasis will be given on ranking lists, based on quality of care and outcomes data. Institute-based practice models will undergo fundamental transformation and government regulations will force players to adopt efficient and effective systems. Hospitals outside hospitals will become real-life scenarios and point-of-care/homecare will gain tremendous momentum. Technology will be the backbone here and AI and Machine Learning will drive the next phase of growth and development in the healthcare delivery space. Local players will continue to compete and will be relevant when it comes to care delivery. Lot of infrastructure push and overall healthcare delivery space will become attractive investment choices across India. Research, innovation, scalable homegrown solutions, digitization of healthcare, and customer-centric models will be the norm.
• Regulations will become essential to curb and regulate the delivery space and the compliance side will witness a sea-change. Integrated regulatory body will become a supportive arm rather than enforcing arm and will see attitudinal change in its approach and execution. The government will be held accountable for the health and wellbeing of its people, and it will have to come clean on the implementation and praise worthy outcomes and sustained improvements.
• Inequalities and inequities and gaps between them will keep narrowing and individual and population health will go hand in hand irrespective of age, gender, socio-economic status, etc.
  Universal healthcare coverage will be an achievable target within the next 10 years.
• Healthcare delivery space will be more unified, uniform, seamless, and will be one of the top three sectors in terms of growth and development of the country.
• Government functioning, both political and administrative, will undergo tremendous change in its working philosophy and will witness more accountability, attention and authority in its holistic approach.