A recent article in a national newspaper titled ‘Covid Fight: Govt system in front, private hospitals do the distancing’ has highlighted that the large-scale battle with Covid in India is being fought by Government hospitals and health institutions. Two-thirds of the hospitals beds and 90% of the ventilators in India are privately owned and yet they are handling less than 10% of Covid patients in the country. It is as if a firefighter were preparing to fight a conflagration and was only allowed to mobilize a highly restricted amount of poorly maintained equipment and material and poorly trained personnel. Calls have been made from various sections of media and leadership to nationalize all private health care enterprises in India immediately. And yet, this is not an optimal solution.
The Covid epidemic has only brought to light the extremely neglected state of health care in the country and the slow deterioration of every medical institution. In my opinion, fixing this diseased health care system requires a comprehensive approach that would be consistent and systematic and not knee-jerk. A wider, non-partisan and disinterested discourse is needed involving the various sections of the system. Yet, bold reforms are needed. Some, though not all, interventions could be among these:
- Strengthen medical schools and graduate medical education (GME) : Education has deteriorated even from the days I did medical school. We had great teachers who were dedicated and caring and drilled the knowledge in us, rigorously and sometimes painfully. Unfortunately, now the students are focused on preparing for multiple-choice questions for entrance exams and do not gain the clinical experience and expertise that is critical for any doctor. Teachers are busy with their own private practice and students are missing out on the most essential aspect of learning. This is not just in India. I recently taught a group of residents from various parts of the world; none of them knew how to hold an ophthalmoscope. I had to take a class on just how to hold the instrument properly and learn how to look in the eye of a patient. Better screening and aptitude tests before students are admitted to educational institutions might be considered.
- Strengthen primary care: Primary care is looked down upon; specialists are in high demand. The basics of engaging a patient are forgotten; how to listen, diagnose, ask, talk, examine are not emphasized. Primary care providers are paid less and have little influence in the care of their patients. Without a strong network of primary care, perhaps like in Cuba, we will not be able to provide quality, reduce costs and create a strong bulwark against such epidemics in the future. Better community and public health, education, nutrition, hygiene, sanitary services, clean water and air, and public safety are essential. The end-point is health; everything affects our inner and outer states of equilibrium or homeostasis.
- Enhance rural care: Rural health is in shambles. Doctors do not like to live in the villages. Basic services are not available. Ambulance and trauma services are minimal. The referral process to secondary or tertiary system is disconnected and uncoordinated. Perhaps a Rural Health Corp can be constituted to ensure health care to our villages. Or doctors can be incentivized to live and practice in the villages.
- Support Ayush: The indigenous systems of health care should not be shunned. They should be encouraged and integrated with the vast network of health care practitioners in the county. Ayurveda, yoga, unani, naturopathy, siddha and homeopathy can be effective if used appropriately and in the right hands. Medical tourism can be encouraged with the help of Ayurveda and yoga hubs across the country for wellness and chronic conditions. The goal eventually should be use to the concept of holistic health and ‘svasthya’ to reach an optimal state of individual development where each person’s true potential is allowed and facilitated to grow and reach its utmost fulfilment.
- Improve and expand government hospitals : Just like ‘Make in India’, we should have ‘Treat in India’. The politicians, senior bureaucrats and leaders need to get treatments in India. This is the only way they will take health care seriously and work towards improving it.
- Remove politics and commercial interests from health care : Big pharma and lobbyists need to be extricated from the health care system. The insidious problem of kickbacks, referral fee and cuts needs to be resolved if any meaningful reform is envisaged. This is the true virus; Covid is only a symptom.
- Enhance emergency and trauma service : A comprehensive approach to this is needed including education, traffic reforms, better roads and railways, ambulance services and trained transportation and evacuation personnel, and advanced trauma centers.
- Advanced facilities for research : Indians needs to become self-reliant in this field. Our research facilities are anemic and dilapidated. We need to bring the best scientists to the country and establish a culture of academic excellence and research. When we are talking about being ‘aatma nirbhar’ we need to do so in maintaining our state of wellness and ‘aarogya’.
- Use of technology : As information technology grows, medical education, rural health care, medical record keeping, primary care, urgent health care, research and diagnostics can be improved. Telehealth, extended reality, artificial intelligence, Internet of things, advanced data analytics, nanotechnology, cryo-technology, and genetic interventions and therapeutics can selectively increase the reach and improve the skills of our workforce while improving quality and utilization of services.
- Reform Insurance: Ayushman Bharat focused on an incidental approach to treatment; the next step should be towards prevention, improving population health while reducing waste, improving metrics and patient and provider education. The money spent on Ayushman Bharat which is mostly going to private entities might be better spent on public health care and rural health care systems.
The entire nation has been mobilized on a warfront. It is the time when our neglect of education and health is addressed on an emergent basis. Without the backbone of a strong health care system no country can be truly advanced. And if India needs to reach a GDP of 5 billion by 2024-5, this might be the most efficient and effective way to do so. A great nation needs a very healthy population.
