Healthcare delivery in the coming year 2018

This past year has been turbulent and unexpected for healthcare providers with changing dynamics of healthcare delivery in India. Of course price capping of medical devices, stringent regulation on private providers, increasing violence on doctors and hospital and widening trust deficit between the doctor and patient has only added to the omnipresent problem of accessibility, affordability and accountability of healthcare delivery in India. Going into 2018, a change in policy and perception will force healthcare providers to adjust their strategies to be cost-competitive and still be relevant to the industry. The main factors that will affect healthcare delivery are

• Change in medical education
• Cost containment
• Legalities of medical practice
• Need for quality and accreditation
• Universal health coverage
• Pluralistic approach to healthcare
• Increased focus on NCDs

Change in Medical Education

The key to building an effective healthcare delivery organization is focus on people. Healthcare workers, be it the physician, nurse, technologist or the support staff will define the success of the organization, backed by robust process. Medical education and medical employment are interrelated so much so that one depends on the other. Less expensive medical education coupled with increased availability of medical seats seems to be the logical solution to counter the looming lack of healthcare workers in India. This has to be complimented with equalization of undergraduate and post graduate seats so that fresh and bright MBBS graduates do not spend precious man-hours preparing for an elusive PG-seat.

Of course, the quality and the process of creating healthcare workforce in India needs an overhaul; where there is provision for a credible teacher, credible institution and an up-to-date curriculum. The idea should be to not only create clinical leaders for India but also for the world.

In doing so we should not overlook the skewed metrics of healthcare workers who are concentrated around larger cities. India should focus on creating intermediate specialist to fill large specialist vacancies in both government and private establishments. Nurses and paramedics should be empowered and creating nurse practitioners is a welcome step in the right direction. However, there is a need to uplift the status of our paramedics and non-medical technicians who vastly contribute towards running a well-functioning healthcare organization.

In all probability, training and skill development will be embraced by the industry in 2018, as healthcare progresses to become the largest employer and job creating industry across the globe. Hopefully the new education policy that is in deliberation and stated to release in early 2018 will take cognizance of and improve the current state of medical education in India.

Cost Containment

India offers world-class healthcare at a fraction of the cost available elsewhere in the world. However, a large chunk of our own population cannot afford quality healthcare at the present rates. We need business models and disruptive ideas to bridge this gap, but draconian policy and clamping industry practices will not provide the desired results.

Cost-containment strategies in healthcare delivery will be the most discussed topic in 2018. Additionally, in 2018, price capping will continue across segments. Talks are on to cap prices of Intra ocular lenses used in cataract surgery, heart valves used in valve replacement surgery and medical consumables like syringe, tubing etc.

The government has also released an advisory for disposable medical consumables. In India, sterilizing and re-using medical consumables labeled for single use is a common practice, to cut down cost of surgery and subsidizing the cost to patient. While the Ministry’s step will make it mandatory to use new consumables with each surgery, the cost of each surgery will rise. This may bring more disdain among different stakeholders. We may be staring at a scenario where a doctor’s professional decision is based on economy and not on clinical judgment and a technology usage is driven by economics rather than clinical relevance.

In India, how will any cost ever be low enough to be called low-cost or affordable when only a small population of the country is covered for health emergencies and majority of the cost of healthcare is out-of-pocket expense? Our policy makers have to think about this. Unless the government focus on outcomes and incentivises hospitals to keep patients healthy a dream of Swasthya Bharat will remain just that a dream!

Legalities of Medical Practice

Medical malpractice and medical negligence is not the same thing. To explain the difference between the two you need to have legal knowledge, but to not know the legal obligations of practicing medicine is not acceptable. Specially now when the conduct of doctors has become the object of intense scrutiny by the media and the public, and no healthcare provider is immune to extreme criticism.

In 2018, more doctors will take to law schools and other course to understand the legalities of practicing medicine in India. While there are about 16 forums that a patient has access to, where complaints against the doctor or hospital can be filed there are no designated forums to address issues of violence against doctors or hospital property. In the years to come, liability insurance policies will become the norm for healthcare workforce and providers.

Much has been said about vicarious responsibility for negligence or malpractice in healthcare delivery. A large section of providers both physicians and owners feel cornered by the law.

There is no doubt that peoples’ right takes precedence amongst all other issues and safety of the patient is of utmost importance. But the sanctity of the doctor-patient relationship and the experience of years of learning should also hold some importance. It will be interesting to see how this saga unfolds and weather the medical community can improve upon the situation.

No doubt, there is an urgent need to educate the healthcare providers on the legal liability of practicing medicine and there is a need to educate patients of their rights. While doing this, one should also make people aware of the limitations of modern medicine and debunk the ultimate healing and Godly status given to medicine. In this regard end-of-life care and palliative medicine become even more important and one cannot emphasize enough the role of counseling.

Quality and Accreditation

The year 2018, will see focused attempts to improve and sustain high quality health services. The recent incidents in Delhi have brought the conversation on quality and safety to the forefront. While the government is planning to implement and enforce Clinical Establishment Act across India, the government health services elude monitoring. Both the healthcare practitioners and patient groups have been demanding that there should be a monitoring and accountability of quality and safety at all institutions government or private.  Will the government look at this suggestion in 2018?

Only a handful of hospitals in India are National Accreditation Board for Hospitals and Healthcare Providers (NABH) accredited.  There is a need for greater participation of healthcare organization for accreditation and bigger incentives for accredited hospitals. A welcome step in this regard is the government’s decision to provide incentives in their schemes for hospitals that are accredited by NABH.  The government can certainly do more and link accreditations to fund allocation to encourage voluntary accreditation.

On the clinical front, there is a need to develop and follow uniform treatment protocols which should be India specific. We cannot aim to implement first world guidelines with third world infrastructure and expect costs to be nil and outcomes equivalent to first world.

Quality has become the focused mantra to make or break a healthcare organization and the meaning of quality has traversed beyond clinical excellence. Empathy and consumer relation will dominate the healthcare delivery scene in India and in this regard effective communication will be the only key to success.

Universal Healthcare

In the recently released National Health Policy, the government has set a target of increasing the public expenditure as percentage of GDP from 1.15 – 2.5 percent by 2025. This hardly seems adequate but what is commendable is the fact that health has become a priority for the government and Universal health coverage is gaining momentum in India. Increased government investment on health is the first step towards achieving universal health coverage. This has to be followed by strengthening health system capacity and creating robust governance and accountability mechanisms to better manage healthcare delivery.

In 2018, Karnataka will become the first state to roll out universal health coverage where all primary, secondary and emergency care will be provided free of cost. The Aarogya Bhagya scheme, will be the amalgamation of seven different health care schemes presently available to the people of Karnataka. Hopefully other states will also follow suit.

Pluralistic approach to healthcare

Traditional medicine has been omnipresent in India and in 2018 there will greater efforts to integrate different forms of medicine with modern medical practice. AYUSH will get a larger share of the healthcare delivery pie as the government formulates new education and healthcare policies. Pluralistic approach to healthcare was envisioned by the National Health Policy 2017. In 2018, AYUSH health workers will get new opportunities to work in the formal health systems.

Increased focus on Non-communicable diseases

One of the biggest challenge for India is the rise of non-communicable diseases and ageing population, both of these will add substantial burden on financial and infrastructure resources. NCDs are emerging as the leading cause of deaths in India accounting for over 42% of all deaths. Most non-communicable conditions are chronic and these chronic conditions cause significant morbidity and mortality both in urban and rural population groups, with a huge loss in potentially productive years (aged 35–64 years) of life.

In 2018, the focus on NCDs will take center stage as the government focuses more on prevention. The private providers will tailor their strategies to be able to address the needs of patients seeking treatment for NCDs. New technologies and disruptive models