Strong Medicine

The challenges of ensuring health for all get short shrift in this book on India’s healthcare industry

Published:March 15, 2014 12:48 am
Doctor is out: A patient at a Delhi hospital. (IE Photo: Oinam Anand) Doctor is out: A patient at a Delhi hospital. (IE Photo: Oinam Anand)

India’s Healthcare Industry: Innovation in Healthcare Delivery, Financing, and Manufacturing

Edited by Lawton Robert Burns

Cambridge University Press

600 pages, Rs 1,295

In Lewis Carroll’s Through the Looking Glass, Humpty Dumpty pompously tells an incredulous Alice that he can make words mean anything he likes. In the real world too, words can mean different things to different people. For a public health academic or activist, equity is a value that places high premium on bridging the health disparities that separate different population groups. To the financial analyst, equity is a market instrument used to invest for profit. When you open a book on “healthcare industry” which has a whole chapter titled ‘Opportunities in Healthcare Private Equity  in India’, there is no confusion about the perspective that defines the  book’s content.

The term “healthcare” too can evoke different perceptions. To the person who is unwell, it means getting better without getting bankrupt. To the care providers, it usually means the availability of infrastructure, drugs and equipment which will enable them to optimally utilise their knowledge and skills. To all who place people’s health above profit, it means an efficiently functioning health system, which delivers a full array of services (health promotion, disease prevention, diagnosis, treatment, palliation, rehabilitation and counseling) to all who need them, with assured access, affordability and quality. To the investor, owner or manager of a corporate healthcare enterprise, it means a market opportunity to sell services in a sector where the dice are loaded in favour of the provider. Hence the term “healthcare industry”.

Lawton Burns, who is the editor of the book and author of many of its chapters, is a professor of healthcare management at the Wharton Business School in Pennsylvania. The book grew out of a course he designed to introduce India’s healthcare system to MBA students at Wharton and the Indian Business School in  Mohali. Not surprisingly, several  of the authors are management  professionals.

The book begins with a description of the “iron triangle” in the US health system, which has to balance between “high quality care, patient access and efficiency/cost containment”.  While stressing the universal nature of this challenge, the book compares the health systems of US and India to identify areas of convergence and divergence. It also compares India with China and other emerging countries. The “healthcare value chain” is described as a link between the upstream “supplier” and the downstream “buyer” with the transactional links involving “players, insurers, providers, distributors and suppliers”. In the editor’s words, “we loosely adopt that framework to focus on several of the key actors in India’s healthcare system: hospitals, physicians, insurers, other payers and financiers (e.g., foundations and private equity), pharmaceutical firms, biotechnology firms and medical device firms”. That captures the essence of the book.

Extensive information is provided on private hospital chains like Apollo, Fortis and Max and biotechnology firms like Biocon, Serum Institute of India and Panacea Biotec. Private sector innovators like Narayana Hrudayalya, Aravind Eye Care, LV Prasad Eye Institute and Vatsalya Hospitals are profiled. Some not-for-profit initiatives like SEARCH (Gadcharoli, Maharashtra), Jan Swasthya Abhiyan (Bilaspur, Chhattisgarh) and the boat clinics of Assam find brief mention. Indian pharmaceutical firms are covered prominently, with market shares and growth potential described in great detail. Government-provided health services are briefly described in the introductory section to complete the picture of India’s mixed health system. There is no doubt, however, that the real hero of the book is India’s expanding private sector.

The composition and deficiencies of India’s health workforce are described in adequate detail, as are the policies related to the pharmaceutical sector. Primary healthcare is briefly alluded to, especially in the context of the National Rural Health Mission. Though both private and government-funded insurance schemes’ limited contribution to primary care is acknowledged, no framework is offered for integrated care. In this context, there is also no reference to Obama’s Accountability Care or the Kaiser Permanente System in the US. How does acquisition by Fortis of well-established primary healthcare chains in Hong Kong link primary to advanced care in its Indian operations?

A whole chapter is devoted to the growth potential of medical tourism. While financial opportunities await large private hospitals, through an expanding clientele of high-paying foreigners, India’s healthcare system will be judged by indicators such as infant mortality rate and maternal mortality or the control of diabetes and hypertension in primary healthcare. Growth in urban tertiary healthcare facilities will not address these priorities.

The fact that health is a well-recognised area of “market failure”, due to the marked asymmetry in information and power between the provider and the patient does not seem to figure in the worldview of the US “value chain”. In a country like India, the role of the government, both as a provider and as a regulator, is especially important to correct this failure. Health systems of China and other emerging economies also point to the need for a strong public sector presence, to promote health as a public good and protect the interests of vulnerable populations. The description of healthcare as an “industry” does not accommodate this vision.

For a book published in 2014, with some references dating to 2013, it is surprising that India’s Twelfth Five Year Plan (2012-17) is not mentioned. The plan’s positioning of universal health coverage as its aspirational goal and a guiding principle for the National Health Mission is not commented upon. The rapid recent growth in emergency care services, through 108 ambulances and similar services, is also not mentioned, though a reference is made to the 911 system in US. In a rapidly changing India, the next edition seems already due.

Nevertheless, the book is a good source of collated information on the structure of India’s healthcare system, even though its focus is on the private players. Its educational value is, however, mainly for those who wish to make more money out of healthcare. The role of the public sector, the many national health programmes that address the nation’s main challenges and the social determinants of health (health beyond healthcare)
get short shrift.

SK. Srinath Reddy

The writer is president, Public Health Foundation of India

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