Strategising Medical Infrastructure Growth In India
Although India's healthcare infrastructure has grown considerably in the past decade, we still have a long way to go. Currently, the country has nearly 70,000 hospitals comprising 19 lakh beds or 1 bed per 1000 population, as against the recommended standard of 3 bed per 1000 population. Hence we need an additional 30 lakh beds to reach the optimal target.
More than 60 per cent of the 19 lakh beds are in the private sector, dominated by small setups and nursing homes rather than the big format 200-bed-or-more hospitals, compromising the quality of the medical asset. Even in the public sector, especially district hospitals and sub-district hospitals, the class of asset is not as per industry standards in terms of area per bed, indoor air quality, crowded internal spaces, water and electricity provision for an emergency, backup power, medical gas systems, etc. Hence, majority of healthcare asset in India needs an uplift if we want to include them as real hospital beds.
Secondly, the private sector is mostly concentrated in urban areas and metropolitan cities. Tier-II cities have hospitals that have grown over the years from a small nursing home and hence does not have a well-planned infrastructure. However, in Tier III cities and villages, the private sector has a negligible presence. The second wave of COVID has been a reality check for the healthcare sector as unlike the first wave, cases have spilled beyond Tier I and II cities. There is an urgent need to correct the skewed distribution of healthcare infrastructure and use technology in a big way to reach expert medical care in times of emergencies.
States like Kerala, Karnataka, Tamil Nadu, Andhra Pradesh, Maharashtra and even Gujarat have fairly well-distributed healthcare infrastructure. On the other hand, Jammu & Kashmir, Madhya Pradesh, Chhattisgarh, Jharkhand and the entire North East region including West Bengal and Orissa score abysmally low on health system indicators. A tangible strategy for bringing uniformity would be for the Government to incentivize the private sector to enter tier III towns and even villages.
A PPP (Public Private Partnership) model where Government provides the hard infrastructure i.e., land and building; and the private sector takes over the operations that can work in India. It is similar to the successful Australian co-payment system. In Australia, the public sector invests in hard infrastructure. The operational partner contributes by equipping the facility. Every Australian pays a federal tax to access subsidised services free of cost. Unsatisfied citizens can opt for private health insurance to access co-paid facilities.
Hence it is not just about building hospitals, financial structuring for sustainability is equally crucial. Government hospitals have a requirement of 600-700 square feet per bed. Since India needs to double hospital beds to meet its citizens' medical demand, the public capital investment to do so would mean millions of dollars. Most western countries provide their citizens access to free/subsidised healthcare. For India, it is not easy because of the sheer volume of patients.
Ayushman Bharat is a pragmatic step towards universal health coverage. It has ensured a large number of citizens who cannot afford tertiary care. However, the Government's role from that of a payer probably should switch to that of provider in semi-urban and rural India. Penetration of Ayushman Bharat can help private players if the PPP model mentioned becomes a reality. It will assure some return on the capital invested by private players and is a win-win situation for both parties.
Another challenge for players in taking healthcare to the last mile is the non-availability of skilled human resources in smaller towns and villages. Currently, about 10 lakh doctors and 18 lakh nurses are available for active service in India. Only 23 per cent of the doctors in India are specialists. To meet the WHO recommended standard of 1 doctor per 1000 population and 2 nurses per 1000 population, we are short of 4 lakh doctors and 10 lakh nurses. To cater to our burgeoning population growing annually at 1.6 per cent, we need to ramp up skilled healthcare human resources — doctors, nurses as well as paramedics. Technology like telemedicine, remote health monitoring and e-education can support service providers in these areas.
The skilling institute needs to be located in Tier II and Tier III towns. Also, emphasis has to shift from not only creating more medical undergraduates but also more postgraduates/super-specialists. The present Government, since it came to power in 2014, has set up 14 AIIMS in non-metros. Simultaneously, they have increased undergraduate medical seats by 50 per cent and post-graduation seats by 80 per cent. But the situation still needs to further improve. It will make it easier for Indian healthcare Inc. to chip in for establishing medical and allied education institutions if certain stringent governmental norms are relaxed like the minimum number of beds and mandatory land parcel of 20 acres etc.
Furthermore, paramedics should be trained to reduce the workload of the medics. The Chinese model of Barefoot Doctors is an example to emulate for rural India; where trained para-medics (Registered Medical Practitioners) were skilled to provide limited primary care services in villages. In India, doctors are not willing to practice in non-metros due to the lack of social infrastructure. 80 per cent of doctors in India are concentrated in urban areas serving a population of just 30 per cent.
Mandatory rural internship or posting can help in this regard and should be adhered to more strictly. The excuse of lack of medical technology and diagnostics in villages should not be a deterrent. Humanitarian aid doctors from developed nations adjust to almost non-existent infrastructure in war-torn countries by virtue of local innovation and do their best with what’s available and is a lesson to take home. Incentivizing these postings will prevent more doctors from escaping the bond. In Sri Lanka, the students on graduating from medical college are posted in rural as well as urban areas. For the more underdeveloped areas, they earn more credits which helps them with post-graduation admission.
Last but most importantly, India needs to up its public health spending from 1.2 per cent to sincerely reform healthcare infrastructure and system. The Government aims to spend 2.5 per cent of the country’s GDP on healthcare by 2025.
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