Prof. (Dr.) Mahboob ali khanMHA,CPHQ,HQM,Pd Harvard University

Osmania University

UNDERSTANDING THE INDIAN HEALTHCARE SYSTEM Threats and Problems

Key Growth Inhibitors

Delivery of qualitative healthcare services is considered a basic need irrespective of age, gender, and culture. Indian healthcare system faces substantial challenges in providing qualitative healthcare.

The key growth inhibitors are:

1. Fastest growing population

2. Changing disease profile and Re-emerging diseases

3. Multilayered Healthcare System / Landscape

4. Lack of or Absence of Infrastructure

5. Paucity of Manpower (Doctors, Nurses, Paramedics)

6. Extremely Low Public Expenditure on Health and its Inefficiencies

7. Inaccessibility of Healthcare Services

Growing Population and Growing Urbanization

Source: UK/MED Source: Equity express.com

Changing Disease Profile: India Shift towards biotech speciality therapies, increased R&D expenditure and acute disease segment will sustain strong growth

Source: IDFC Institutional Securities, Indian Pharma, 2010 Source: NSSO Morbidity & Healthcare Survey, McKinsey’s Analysis, 2004

Per 1000 cases

http://usf.vc/wp-content/uploads/2013/12/NCD-burden-India_PwC-copy.jpg

• India which makes up 16.5 percent of world’s population and faces a significant burden of diseases. • It accounts for “a third of diarrheal diseases, tuberculosis, respiratory, parasitic infestations, prenatal conditions; • A quarter of maternal ailments; • A fifth of nutritional deficiencies; • Second largest number of HIV/AIDS cases in the world;

FEDERATION OF INDIAN CHAMBERS OF COMMERCE AND INDUSTRY (FICCI), INDIA NEEDS TO SPENDS AROUND US $203 BILLION, IF MISSION OF ACHIEVING “HEALTH FOR ALL” IS TO BE ATTAINED.

Multilayered Healthcare Landscape

Source: Central Bureau of Health Intelligence

Lack of Healthcare Infrastructure

Source: Novartis, Arogaya Parivar, Health for Poor, 2010

Human Resources Shortages: India

Source: World Health Statistics, 2013, WHO, ICMR, Aranca Analysis

Human Resources Shortages: IndiaIndian healthcare expenditure has grown slower than the economy

Source: WHO, E&Y Analysis

http://cdn-www.ceicdata.com

Different Healthcare Parameters: India

Source: World Health Statistics, 2013, WHO, ICMR, Aranca Analysis

Inaccessibility of Healthcare Services: India

• Physical Reach / Accessibility of a healthcare facility which is having an outpatient department (OPD) for common ailments, and an inpatient department (IPD) for hospitalization. These facilities may either be public or private in nature within 5km from the place of residence or work.

• Availability/Capacity means availability of the requisite healthcare resources to provide patient treatment, i.e. doctors, nurses, in-patient beds, diagnostics, consumables, etc. it is governed by minimum specifications defined by the Government of India for public healthcare facilities, and WHO.

• Quality/Functionality means quality of the healthcare resources available at the point of patient treatment.

• Affordability means the ability of a patient to afford complete treatment for the illness or disease.

Source: IMS Institute for Healthcare Informatics, Understanding Healthcare Access in India, June 2013

India and Its Neighbors (SAARC Countries)

Source: http://thecalibre.in/wp-content/uploads/2013/01/Number-fetish.jpg

Healthcare Challenges: India

Low Government Spending

India has a low level of government spending

on healthcare, at 1% of the GDP.

Business Monitor International forecasts

that healthcare expenditure in India

will increase from US$49.7 billion to

US$86.9 billion between 2009 .and 2014, a rise of 75%

Poor / Depleting Infrastructure

Healthcare infrastructure is poor, compared to urban

areas. The doctor patient ratio

in rural areas is 1:20,000, versus the

urban ratio of 1:2000. The quality and

availability of medicines in rural areas

is dubious, where counterfeiting and

spurious drugs us is rampant.

Limited Affordability

Healthcare is a low priority when it comes to income allocation,

with average consumer expenditure on

healthcare at just 7%. 80% of the rural

population is on a daily wage, income levels are as low as <US$1.78 per

day.

Low Awareness of Disease and

Possible Treatment

People here have lower literacy levels and lack

awareness about various diseases and

their treatment option. They rely mainly on alternative forms of treatment such as

Ayurvedic medicine, Unani, and

Acupuncture.

Poor Basic Hygiene and

Living Conditions

33% of the diseases in rural areas are related

to unsafe drinking water and poor

sanitation. This is because 80% of rural inhabitants lack adequate sanitation, and 70% don’t have safe drinking water.

Government Appointed Review & Its Findings

All reviews have pointed towards:• Occurrence of major legislative gaps and poor

implementation• Ineffective implementation of Laws and Policies• Lack of rules and poor enforcement• Fragmented and uncontrolled nature of private healthcare

delivery system• Lack of uniform standards• Non coverage of laboratories or diagnostic centres• Also information about the number, role, nature,

structure, functioning, and quality of healthcare in private hospitals remain inadequate or poor.

• Absence of national regulations regarding provider standards and healthcare treatment protocols, over diagnosis, over treatment, and maltreatment is rampant practice.

Initiatives By Government

Rural-Urban Difference

Developing more equitable healthcare

infrastructure between urban and

rural areas.

Convert Primary Healthcare Centres

into Community Healthcare Centres

Health Resource and

Infrastructure

Meeting global per capita infrastructure

standards

Addressing variations at the state level

Public Healthcare Facilities and

Treatment Quality

Improving Critical Care Facilities

Addressing Services level in public

channels by effective utilization of public

infrastructure.

Affordability

High proportion of out of pocket expenses and

relatively expensive in-patient care.

Limited reach of benefits to the

intended beneficiaries.

Major Challenges

• Indian healthcare establishments have pitiable operational strategies, absence of documented waste management and disposal policy, very poor budgetary support in the government run hospitals, private hospitals ignore the rules for monetary consideration, untrained ward attendants, and other supporting staff.

• There are no waste management committees at present in Indian hospitals which should essentially be consist of the head of the establishment, all the departmental heads, hospital superintendents, nursing superintendents, hospital engineers with a waste management officer along with an environmental control advisor and an infection control advisor.

• Insufficient support and guidance from regulatory agencies further complicates the problem of waste management. Regulations in the form of waste reduction and recycling targets, carbon credit earnings, development of minimum energy efficiency standards for equipments are necessary for prevention of pollution and reduction of environmental load on sustained basis.

• Adequate and requisite number of sanitary landfills is lacking in India.• Resistance to change is often a barrier to implementation of new programmes.

Major Challenges

• It is the ethical, social responsibility, and duty of state, legislators, hospitals, healthcare professionals, and the general public to make sure that environmentally acceptable waste disposal techniques is introduced and implemented effectively.

• At present we have good enactments of laws, but political will is lacking to enforce these laws. • There is no forum for ordinary citizen to approach for compensation. • The present system provides only one remedy, that is, to go to ordinary civil courts, which are

overburdened with heavy pendency, and it may take decades to get relief to compensate the loss caused by the medical wastes under the head of public nuisance.

• There is no effective tribunal like consumer forum to provide a speedy remedy for the persons infected with disease by medical waste. The Environmental Tribunals have to be constituted.

• Training Development of safe and effective system of bio-medical waste management along with handling protocols, detailed institutional plans, strict policies, appropriate training and feedback programs for all the healthcare workers is very important.

Conclusion: General

• India lags behind in in key healthcare indicators

• There is Growing Burden of Disease and Disease Mix

• Inadequate and Poor Healthcare Planning (Top Down)

• Inequitable distribution of resources between different States as well as Urban Rural settings

• Shortfall of Physical Infrastructure

• Shortfall of Trained Manpower (Doctors, Nurses, Para-medics)

• Miniscule Healthcare Budget by Governments

• High Cost of Advanced Treatments

• Low Insurance Penetration

• Unregulated Private Sector (Only 244 hospitals in India are accredited by NABH)

ReferencesCORPORATE RESEARCH REPORTS: • HEALTHCARE IN INDIA: A REPORT BY BOSTON ANALYTICS, JANUARY 2009• GLOBAL INFRASTRUCTURE: TREND MONITOR INDIAN HEALTHCARE EDITION: OUTLOOK 2009 –2013 BY KPMG• STRATEGIES FOR PROVIDING EQUITABLE HEALTHCARE, BY ECS LIMITED, MARCH 2008• PHARMACEUTICAL OFFSHORING LANDSCAPE, ZINNOV MANAGEMENT CONSULTING, SEPTEMBER 2008• INDIAN PHARMACEUTICAL INDUSTRY ON COURSE OF GLOBALIZATION, DEUTSCHE BANK RESEARCH, APRIL 2008• HEALTHCARE IN INDIA: EMERGING MARKET REPORT 2007 BY: PRICEWATERHOUSE AND COOPERS (PWC)• HEALTHCARE OUTLOOK, TEN INDUSTRY TRENDS 2007, A QUARTERLY REPORT BY TECHNOPAK, FEBRUARY 07 /

VOLUME 1• HEALTHCARE OUTLOOK, NEW PARADIGMS IN HEALTHCARE DELIVERY 2007, A QUARTERLY REPORT BY

TECHNOPAK, FEBRUARY 07 / VOLUME 2• HEALTHCARE OUTLOOK, TRENDS IN HEALTHCARE DESIGN 2007, A QUARTERLY REPORT BY TECHNOPAK,

FEBRUARY 07 / VOLUME 3• HEALTHCARE, MARKET OVERVIEW, INDIA BRAND EQUITY FOUNDATION (IBEF) OCTOBER 2007• OVERVIEW OF THE HEALTHCARE INDUSTRY IN INDIA, THE INDO ITALIAN CHAMBER OF COMMERCE AND

INDUSTRY, APRIL 2007• HEALTHCARE REPORT: BY ERNST & YOUNG, INDIAN BRAND EQUITY FOUNDATION (IBEF), 2006• BOOMING CLINICAL TRIAL MARKET IN INDIA: RNCOS REPORT, NOVEMBER 2007• DRAFT NATIONAL PHARMACEUTICALS POLICY, 2006, PART - A (CONTAINS ISSUES OTHER THAN STATUTORY PRICE

CONTROL), DEPARTMENT OF CHEMICALS AND PETROCHEMICALS, GOVERNMENT OF INDIA, DECEMBER 28, 2005• HEALTH ATTAINMENTS AND DEMOGRAPHIC CONCERNS: NATIONAL HUMAN DEVELOPMENT REPORT, 2001:

CHAPTER 5• THE STATE OF HUMAN DEVELOPMENT: NATIONAL HUMAN DEVELOPMENT REPORT, 2001: CHAPTER 1• HEALTHCARE IN INDIA, CARING FOR MORE THAN A BILLION: BY SRIVATHSAN APARAJITHAN Y, MATHUR SHANTHI,

MOUNIB EDGAR L., NAKHOODA FARHANA, PAI ADITYA AND BASKARAN LIBI, IBM INSTITUTE OF BUSINESS VALUE, IBM GLOBAL BUSINESS SERVICES

• CASE STUDY ON MANIPLE CURE & CARE: INDEGENEOUS CONCEPT THAT COMBINES HEALTHCARE AND RETAIL IN A SINGLE FORMAT: BY PRICE WATER HOUSE AND COOPERS(PWC) AND DYNAMIC VERTICAL SOLUTIONS

• INDIAN PHARMACEUTICAL INDUSTRY: ISSUES AND OPPORTUNITIES: RESEARCH AND MARKETS REPORT ( http://www.researchandmarkets.com/reports/35229)

SUMMARIES:

• INADEQUATE REGULATIONS UNDERMINE INDIA'S HEALTHCARE: BY: MUDUR GANPATI: BMJ 2004; 328;124- DOI:10.1136/BMJ.328.7432.124-A

• HEALTH CARE IN INDIA: LEARNING FROM EXPERIENCE: BY THE WORLD BANK GROUP• HEALTHCARE INDICATORS: BY MS. MUKHERJI SRIMOTI, COMMERCIAL SPECIALIST, THE U.S. COMMERCIAL SERVICE IN

INDIA, THE AMERICAN CENTER, NEW DELHI• INDIA’S NATIONAL HEALTH SYSTEM PROFILE: WHO• OPPORTUNITIES IN HEALTHCARE: “DESTINATION INDIA”: FICCI AND ERNST & YOUNG.• RURAL HEALTH CARE SYSTEM: THE STRUCTURE AND CURRENT SCENARIO• INTRODUCTION TO NURSING AND HEALTH CARE DELIVERY SYSTEM IN INDIA• A POLICY FRAMEWORK FOR REFORMS IN HEALTH CARE, PERSPECTIVES ON HEALTH CARE IN INDIA: BY PRIME

MINISTER’S COUNCIL ON TRADE AND INDUSTRY• FAILURE OF PUBLIC HEALTHCARE SYSTEM: CJ: BY SINGH CHANDRA SHEKAR, FEBURARY, 2008• FINANCING THE HEALTH CARE SECTOR IN INDIA: BLOG BY DR SINGH HARMEET, MBA (BIRMINGHAM)• IN CHINA, INDIA, HEALTH CARE BURDEN SHIFTS TO POOR, GROUND-LEVEL IMPLEMENTATION 'IS SIMPLY NOT THERE':

BY POWELL ALVIN, HARVARD NEWS OFFICE • STRENGTHEN THE INDIAN HEALTHCARE INDUSTRY (RECOMMENDATIONS): MODE 1 GATS REPORT INDIA PAGE 83, 84• ROLE OF PRIVATE SECTOR IN HEALTH CARE IN INDIA CHALLENGES, OPPORTUNITIES & STARTEGIES: BY LATH G K, CEO,

APOLLO HOSPITAL BILASPUR, MP• UNHEALTHY PRESCRIPTIONS: THE NEED FOR HEALTH SECTOR REFORM IN INDIA: BY SUNIL NANDRAJ, INFORMING

REFORMING, THE NEWSLETTER OF THE INTERNATIONAL CLEARING HOUSE OF HEALTH SYSTEM REFORM INITIATIVES ICHSRI, APRIL-JUNE 1997, PP. 7-11.

• MEDICAL TOURISM IN INDIA: ISSUES AND CHALLENGES: BY CHACKO PHEBA, THE ICFAI UNIVERSITY PRESS.• HEALTH INSURANCE IN INDIA: OPPORTUNITIES, CHALLENGES AND CONCERNS: BY MAVALANKAR DILEEP AND BHAT

RAMESH, IIM AHMEDABAD• INDIA BRAND EQUITY FOUNDATION (IBEF), MARCH 2013, AUGUST 2013 REPORT (WWW.IBEF.ORG)• HEALTHCARE INDIA SECTOR NOTES, MAY 2014, (WWW.IIMJOBS.COM)• INDIAN HEALTHCARE SYSTEM – OVERVIEW AND QUALITY IMPROVEMENTS, DIRECT RESPONSE, 2013:04, SWEDISH

AGENCY FOR GROWTH POLICY ANALYSIS , WWW.GROWTHANALYSIS.SE • INDIAN PHARMA, INC.: CAPITALIZING ON INDIA’S GROWTH POTENTIAL, www.pwc.com/India• INDIAN PHARMA INC. CARING FUP OR NEXT LELVEL OF GROWTH, www.pwc.com/India

ReferencesWebsites: • www.technopak.com• www.kpmg.com/infrastructure• www.ibef.org• www.dbresearch.com• www.dynamicverticals.com• www.bostonanalytics.com• www.ibm.com/healthcare/hc2015• www.pwc.com/globalhealthcare• www.wikepedia.com/healthcare• www.ficci.com• www.timeswellness.com• www.fortishealthworld.com• www.whoindia.org• www.who.int• www.mohfw.nic.in• www.crisil.com• www.pharmabiz.com• www.pharma.org

Journals

• JOURNAL OF THE ACADEMY OF HOSPITAL ADMINISTRATION• INDIAN JOURNAL FOR THE PRACTICING DOCTOR• JOURNAL OF HEALTHCARE AND MEDICAL TECHNOLOGY AND MANAGEMENT • INDIAN JOURNAL OF MEDICAL ETHICS• THE PHARMA REVIEW AND PHARMA TIMES • JOURNAL OF HOSPITAL PHARMACY

Other Publications:

• MINISTRY OF HEALTH, GOVERNMENT OF INDIA• INDIAN MEDICAL COUNCIL & INDIAN DENTAL COUNCIL• EXPRESS HEALTHCARE MANAGEMENT• INDIAN HEALTHCARE FEDERATION• MEDICA: PHARMACEUTICAL INDUSTRY PUBLICATIONS• MEDICA: HEALTHCARE SERVICES PUBLICATIONS

Chapters:

• COMPETITION CONCERNS: THE PHARMACEUTICAL INDUSTRY BY CUTS INTERNATIONAL• CHAPTER 10: DRUG PRICE DIFFERENTIALS ACROSS DIFFERENT RETAIL MARKET SETTINGS: AN ANALYSIS OF RETAIL

PRICES OF 12 COMMONLY USED DRUGS: BY GODWIN S K AND VARATHARAJAN D., HEALTH ADMINISTRATOR VOL: XIX NUMBER 1: 41-47

• HEALTHCARE POLICY AND ADMINISTRATION IN INDIA: BY SAPRU R K, STERLING PUBLICATION, II EDITION, CHAPTER 15, PAGES 228-249.

My Books:

• Indian Health Sector and Healthcare System: A critical Insight, LAP Lambert Academic Publishing, Germany, 2012, ISBN-10: 3659268895, ISBN-13: 978-3659268892, Prashant Mehta

• Indian Retail Analytics: An In-depth Study of Indian Retail Market, its Dimensions, Opportunities, Problems, and Prospects, LAP Lambert Academic Publishing, Germany, 2012, ISBN-10: 3659147303, ISBN-13: 978-3659147302 Prashant Mehta

My Publications:

• Legal Provisions and Management Perspectives of Biomedical and Hospital Waste in India. Journal Club for Management Studies (JCMS),1(II), 11-36 (2014).Dr. Prashant Mehta. ISSN No : 2394 - 3033, V – 1, I – 2, 2014

• Biomedical Waste Disposal: Indian Perspective: Scholasticus, Journal of National Law University, Jodhpur Vol. 5 No. 1, September 2007, Prashant Mehta, ISBN: 0975-1157, Indexed