An extract from a report by: FICCI & E&Y
Rapidly transforming medical technology, availability of advanced diagnostic and therapeutic equipment, together with changing practice pattern of clinicians has revolutionised the way healthcare is being delivered globally. The healthcare sector is reinventing itself faster than ever, working on evolving, innovating and modifying care delivery models for integrated and value-based care, which will shape the future of healthcare.
Emerging economies like India however, need to tackle the challenges of rising costs, inconsistent quality, inaccessibility to timely care, as well as confront the dynamics of globalisation, consumerism, changing demographics and shifting disease patterns with increase in lifestyles and chronic disease, along with the proliferation of new treatments and technologies.
With the launch of ‘Ayushman Bharat’ – the Indian government has demonstrated its strong commitment to providing healthcare for all, aligned to the SDG 3 goal. Healthcare has also been included as a key parameter in the country’s development plan through various comprehensive initiatives including Swachh Bharat, Digital India, Skill India, Start-up India, Make in India etc. over recent years. However, we have a long way to go before we can call ourselves a healthy nation in entirety.
This vision can be achieved only with collaborative and outcome-based healthcare delivery both in public and private healthcare facilities. The government needs to implement the standardization of treatment protocols and billing process, along with Patient Health Records (PHR), Digital Claim Disbursement platform, Electronic Health Records (EHR) and SNOWMED CT as a part of the National Digital Health Ecosystem. Indeed, this is a tall order, but must be aimed to be achieved in next 5 years. The private healthcare providers with 70% of bed capacity and 60% of in-patient care are key stakeholders. While the government can mandate the adoption of these standards in public sector, market forces will ensure their adoption in private sector. Although, the concerns of financial sustainability of the private providers need to be addressed, along with affordability for the patient, through transparent and scientific costing practices.
Hence, it is time that we re-engineer the healthcare ecosystem with systemic and structural changes, keeping the ground realities in mind, through innovative and sustainable models of care delivery as well as business processes. But above all, there is an urgent need to bridge the ‘trust deficit’ between the patient and the doctor; patient and the hospital; as well as government and the private healthcare provider for the Health of the Indian Healthcare. Owing to this, the Health Services Committee of Federation of Indian Chambers of Commerce and Industry (FICCI) felt the need to analyse the current scenario and come up with viable solutions for benefiting all stakeholders.
Tailoring the hospital care model for inclusion
With the state of the capacity of public healthcare and delivery being sub-optimal which is expected to continue in the near future, greater than 70% of capacity and ~60% of inpatient care is being served by the private healthcare system in India. It is imperative that the private sector not only thrives sustainably but also invests in further capacity expansion. Despite being the bedrock of capacity and capability, the private sector has been facing significant sustainability pressures driven by internal and external challenges which is evidenced by the sector’s poor financial health. The already constrained financial health of the sector is likely to be further impacted negatively with the launch of government’s ambitious Ayushman Bharat Yojana which aspires to provide health cover to 45% of the country’s poorest population, constituting 60 crore beneficiaries.
A comparison of select procedure costs with the reimbursement tariffs offered under the Ayushman Bharat scheme highlight that not more than 40-80% of the total costs are covered by the tariffs.
It is expected that with allocation of only 25% of capacity to Ayushman Bharat patients, multi-speciality National Accreditation Board for Hospitals & Healthcare Providers (NABH) accredited hospitals are likely to witness 15-25% decline in ARPOBs (Average revenue per occupied bed day), 25-50% decline in EBITDA and 35-60% decline in ROCE if no change is undertaken by them in their operating model.
Consequently, private hospitals which allocate ~25% of their bed capacity for Ayushman Bharat patients will have to focus on driving 30-35% efficiency improvement across major cost heads to achieve healthy profit margins and return on capital employed slightly higher than the cost of capital of 14%. Any further capacity allocation beyond 25% to such scheme patients will necessitate additional efficiency improvement beyond 35% which may not be tenable without compromising patient safety and quality of care delivered.
Building a model for true care focused on primary care, wellness and health outcome
Prioritising focus on integrated care and robust primary care system
The Alma Ata Declaration of 1978, a significant milestone in the field of public health, identified effective primary care as the bedrock of a health system that aims for universal healthcare. The declaration defined primary health care as “essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self- determination”
It is evident from the state of healthcare world over, developed and developing included, that the spirit of the Declaration was not pursued. Instead, a hospital-centric model gained prominence resulting in a universal challenge of growing disease burden, widening gap in access to care and the unsustainable cost of healthcare. However, there has been a call from the WHO (World Health Organization) in recent times to revisit the Declaration and make it a reference point while designing the health systems of the future.
In India, the legacy issues in primary care such as poor availability, high shortfall and poor quality of physical infrastructure and human resources exist. Several new challenges such as the shifting disease profile from acute to chronic too have emanated. However, there are new opportunities emerging with advancements in technology across telemedicine, point of care devices and Artificial Intelligence (AI). So, there is a need for India’s primary care system to adapt to the changing dynamics and move from management of communicable diseases and provisioning of primarily maternal and child health services to an integration of health services and noncommunicable disease interventions. The interest of private players in primary care will be selective given the economics criteria. Recognizing the fact that primary care is far more fundamental for the health of the nation, the Government could continue to play a predominant role and actively invest in filling critical gaps as also reflected in the National Health Policy 2017’s recommendation to direct upto two-thirds or more of public health spending in primary care.
Modernisation of primary care facilities to boost utilisation
Under the Ayushman Bharat program, 150,000 existing Sub Centers (SC) and Primary Health Centers (PHC) are to be upgraded into Health and Wellness Centers (HWC) with a widened scope of primary care services by 2022. The program is a step in the right direction towards the goal of Universal Health Coverage (UHC) as primary care is the foundation of healthcare for all.
A UHC pilot13 launched in early 2017 in 3 blocks of Tamil Nadu to assess the success of Health Sub Centers (HSCs) in provision of primary healthcare has been found to be effective in reducing the Out of Pocket Expenditure (OPE) by converting patients seeking care at private clinics or PHCs and above public facilities to the upgraded HSCs. Some of the improvements after the pilot include:
• HSCs share of overall Out Patient (OP) healthcare: < 1% 15-23%
• Share of private hospitals for OP care: 41-51% 21-24%
• OPE: 77-93% drop per visit by patients seeking healthcare in public facilities
• Government spending: 67% drop in average per capita public expenditure from diversion of patients from PHC/ CHC (Community Health Center)/ GH (Government Hospital) to HSCs: Rs. 300 Rs. 100 per OP visit
As on 22
February 2019, approximately 10,252 HWCs had been operationalized in various
states, which is just over two- third of the targeted 15,000 that was to be
achieved by March 2019. At the current pace, the ambitious rollout target of
HWCs for the next three years seems quite challenging to achieve.
While the intent of the plan to upgrade Health Sub Centers is positive, there is no evidence to build confidence on the effective implementation, given that the allocation itself, which is the pre-condition for implementation, falls short by 51%. A lot more impetus could be lent since primary care is the firm foundation of the healthcare system in India.
context of the current challenges in primary care delivery in India and the
emerging opportunities from the Ayushman Bharat- Health and Wellness Centers
(AB-HWC), there are five broad areas of focus for strengthening primary care
delivery in the country.
Enhance the role of primary care givers:
• Non-Physician Clinician (NPC) led team-based care
• Attracting and retaining in rural areas
• Capacity building of family medicine practitioners
• Empowerment of primary care nurses/ ANMs
• Improved community engagement
• Leveraging informal care providers
Expand the scope of care and leverage technology:
• NCD management
• Point of care diagnostics (POCD)
• Artificial Intelligence (AI)
Engage private players
• Innovative primary care models in India
• Public Private Partnerships
• Innovative outcome-based financing
Employ good governance
• Robust gatekeeping mechanism
• Accountable care model
• Managing partnerships
Economize delivery of care
• Culture of cost containment
• Effective supply chain
“Primary care, to be effective in delivering all the services expected of it, must have a multi-layered, multi-skilled workforce which is technology enabled, well connected to other levels of health care and optimally engages community resources for health promotion, self-care and appropriate use of health services. It has to provide continuity of care while forming the foundation of multi-level delivery system for universal health coverage.”
Prof. K Srinath Reddy, President, Public Health Foundation of India (PHFI).
The need to mainstream and upskill Non-Physician Clinicians (NPCs) at the last mile in the Health Sub Centers
The unavailability of clinical staff at the last mile (SCs and PHCs) is a reality that will take some time to improve across the country to adequately meet the required demand. Even if the supply were to increase, distribution will remain a challenge given the rural-urban skew and state-wise skew with states such as Bihar, Jharkhand, West Bengal, Uttar Pradesh and Maharashtra having poor primary care access. To meet the universal healthcare aspirations, it is imperative to consider upskilling easily available resources that are also committed to participate in the under-served geographies.
What can be done?
• Non-Physician Clinicians (NPCs) could be leveraged as Mid- Level Health providers (MLHPs) at SC-HWCs to build NPC-led team-based primary care delivery in India, where MLHPs are made accountable for the health indicators in the served community.
• Creation of limited license practitioners under the National Medical Commission (NMC) Bill is a welcome move, however the Government may consider transferring the program to a separate council (Allied Health and Professionals) to develop a specific program for the creation and sustenance of the cadre through identification of core competencies, standardization of curricula and a well-defined career path.
• The National Board of Examination (NBE) and the Allied Health and Professional (AH&P) Council must choose the curriculum to be designed to develop both modern medicine (primary care) and public health competencies.
• A unified national program could be developed to include compulsory service, rural incentives, a supportive eco- system and a block or district level career path to attract and motivate personnel to work in rural areas.
• Government should target to create a cadre of 1.5 lakh MLHPs by 2022 to lead the teams of Multi Purpose Workers (MPW) and Accredited Social Health Activists (ASHA) at HWC.
Some key learnings from Global and Indian experiences
The WHO’s Global strategy on human resources for health: Workforce 203016 highlights the potential of mid-level health workers in inter-professional primary care teams. In India, almost all PHCs in Chhattisgarh currently are led by NPCs called as Rural Medical Assistants (RMAs) who underwent a three-year diploma in modern medicine and surgery, the course started in 2001 but ran into conflicts and was discontinued in 2008 following litigations by the Indian Medical Association (IMA). A comparative assessment of performance of physicians and NPCs in Chhattisgarh by Public Health Foundation of India (PHFI) and National Rural Health Mission (NRHM) concluded that clinical care providers with short training duration (RMAs) are a competent alternative to physicians. The study also indicates that though AYUSH doctors (Ayurveda, Yoga, Unani, Siddha and Homeopathy) are not the best alternative to physicians, additional allopathic training may improve their competence, which the Government intends to do, possibly through a bridge course. The study suggests that successful creation and sustenance of such mid- level cadre would require support from medical establishments through a policy for local recruitment and the need for a clear career path with provisions to become fully qualified after some years of service.
“A definitive is that healthcare must be equitable and inclusive to be true to its intent. It is wonderful that a very timely and pertinent report has been put together to help all in rethinking and redesigning processes and steer the course towards requisite decision making. Healthcare is at the cusp of tremendous change and the need of the hour is for radical thinking and disruptive solutions to address the dynamic economic and social milieu. Above all, the extent of the impact is the best barometer and the journey towards it would need to accommodate current expectations for greater involvement, clarity, and convenience in the healthcare delivery process. Furthermore, a healthier nation is the bedrock of a healthier economy.”
Ms Sangita Reddy, Senior Vice President, FICCI and Joint MD, Apollo Hospitals Enterprise Ltd
Characterising current state
There exists a unique situation in the Indian healthcare sector, wherein the principal stakeholders, i.e., government, provider and patient are dissatisfied and exhibit indignation. However, the truth is that none of them can claim a moral high ground but yet are also a victim of the current situation. Indignation is largely a result of a skewed perception of all, caused by bounded rationality and at times blinded self-interest, with provider being the most affected and consequently the least trusted.
While the current state is chaotic and undesirable, it is better than the previous situation, which was characterised by a general sense of apathy towards healthcare- both by the general public and the policymakers- that has led to the abysmal state of healthcare today. The biggest positive in this chaos is the strengthening of the voice of the patient, which alone has the power to catalyse the providers and policymakers to take action towards providing quality and affordable healthcare. In order to measure and assess the mood of the most important stakeholder, i.e., patient, a survey of 1,000 respondents was carried out as part of this study. Results from this survey have been used to highlight some of the gaps in patient experience which contribute to the trust deficit.
Our survey revealed that 61% of patients did not believe that hospitals acted in their best interests. In a similar 2016 survey, 37% patients had indicated such a perception. These trends are reflective of a widening trust deficit between patient and provider which has only worsened over the years.
Need for building trust
Trust is critical for the effective and efficient running of any system. However, in the context of healthcare, this becomes non-negotiable. It is a common belief that more than the medicine, it is the implicit trust in the medicine and prescriber of medicine, i.e., doctor, that cures the patient. One can only imagine how miserable a health system will be if this sacred trust is compromised with beyond a point.
A lack of trust may push people into the hands of quacks or improperly trained and certified individuals which will be a major setback for healthcare services and providers and disastrous for the community in the long run. Given the current environment where the provider is the least trusted in the healthcare ecosystem and rising number of incidents of violence against doctors, defensive medicine may lead to an increase in costs because of physicians recommending diagnostic tests or medical treatment simply because they do not want to take any chances
In a country like India where the poorest of the poor prefer private care, despite the tremendous financial hardship, given the abysmal state of public healthcare services, it may be catastrophic to have an adversarial relationship between private providers and the government.
Private providers also need to shed their tendency to defend the status quo, which is not aligned to serve the government’s agenda of mass healthcare.
The government must also recognize the challenges of private providers and allow them time to realign their models with the emerging agenda. Otherwise, the risk is that the conscientious player will find the economics unfavorable and the less scrupulous may see this as a commercial opportunity to exploit, thereby compromising patient safety and ultimately the cost and quality of care- defeating the very purpose behind the policy.
Trust is often seen as a forward-looking metric determining future behavior compared to patient satisfaction which is deemed as backward looking based on experience.
“A hospital based system built on a non existent primary care is a sure recipe for disaster as it is clearly unaffordable and unsustainable. Effective primary care not only reduces one-third of hospitalisation but by prioritising well being over sickness, it has the potential to effectively reduce risk factors and address the causal and distal determinants to disease and illness. Achieving this is far more complex than what is assumed. It necessitates new institutional architecture in the form of Departments of Public Health. It is when such an instrumentality is created that there will be the much needed focus to develop distinct Public Health Cadres and the required non medical human resources that have the requisite skills and capacities to deal with population health issues and a comprehensive primary health care system founded on cross-sectoral linkages.”
K Sujatha Rao, Former Union Health Secretary, GoI
Evolving a framework for trust enhancement
Our survey revealed that while successful treatment is the foremost expectation of the patient, it is certainly not the only expectation. Today’s patients have demands from the hospital spanning across their entire experience journey, not just limited to treatment.
However, the overall
satisfaction levels with hospital experience seem to have only dropped over the
last two to three years as the number of patients who did not report being
happy has gone up from 22% in 2016 to 49% as per the current survey.
This indicates that while expectations are there, the current performance is below expectations and has only worsened over recent years.