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Health and education are fundamental pillars of society. These are basic civil rights as well. A year before our Independence, The Bhore Committee presented a report that became the template on which independent India built her healthcare infrastructure, from Primary Health Centres (PHCs), Secondary Health Centres (SHCs) to District hospitals. Planning and provision of preventive care, along with curative care, were significant recommendations for public health. PHC was suggested for a population of 40,000. They were to be staffed by two doctors, one nurse, four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist, and fifteen other class IV employees.
Secondary centres provided support to PHCs and coordinated and supervised their functioning. Based on these seminal recommendations, many states, over a period, excelled in providing healthcare at the ground level based on key health parameters—an increase in life expectancy and a decrease in infant and maternal mortality rates. However, this is not uniform across our vast country, and various gaps need to be addressed as a priority. Let us use ‘Amritkaal’ to ensure that by 2047, we establish a truly functional healthcare delivery system at PHC and SHC levels for ‘Bharat’.
From the 1950s to the 80s, healthcare delivery was primarily managed by the public sector. A few trust hospitals existed but were limited to a few metropolitan cities. It was in 1983 that India witnessed the emergence of the private sector in healthcare substantially. Dr Prathap Reddy turned his dreams to life with the first Apollo Hospital in Madras (now Chennai).
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Being a clinician in the US, he used his training and experience to develop a modern healthcare infrastructure with state-of-the-art medical equipment at par with any developed country. This attracted medical talent from across India and abroad to function and provide best-in-class healthcare comparable to the best hospitals in the world. Apollo expanded its outreach by establishing similar facilities in Hyderabad in the late 1980s and in New Delhi in the mid-1990s.
During those days, the latter was the fourth largest corporate hospital across the globe—a truly visionary step forward with the best medical infrastructure. It was also in the late 1980s when Dr Naresh Trehan, a young heart surgeon working in New York, returned to India and assisted in establishing Escorts Heart and Research Institute with support from the Escorts group. Before the establishment of Apollo and Escorts, the only option for superior quality high-end cardiac care was the UK or the US. As patients started experiencing cardiac care here, equivalent to or better than what was available outside India, high-end cardiac care started getting established in India.
These two harbingers of change in the Indian healthcare ecosystem extended the idea of private enterprise in healthcare; encouraged other entrepreneurs to build tertiary and later quaternary multispecialty facilities, such as Narayana, Fortis, Max, Manipal, and Medanta emerged as prominent healthcare providers. Growth in the private healthcare ecosystem, which had the best healthcare infrastructure, attracted the best medical talent within and from outside India to come on board and practice medicine. A reverse brain did happen, and it continues.
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Medical Value Travel (MVT) is accelerating growth and helping us generate significant foreign exchange. Hospitals can avail of customs duty reduction tied in with foreign exchange they generate from MVT for the purchase of costly medical equipment—an excellent initiative from our government that has boosted medical infrastructure.
Our honourable Prime Minister has expressed his desire several times that India increases its MVT capability substantially—this will not only enable huge revenue generation but also position India well amongst other nations. Present healthcare infrastructure needs to expand to cater to the enhanced demands of our populace and cater towards MVT. The way Production Linked Initiative (PLI) rolled out for the Indian industry, something similar will help attract investments to enhance bed capacity and bring in the latest medical technology to attract more MVT.
Healthcare has huge employment generation capabilities—National Health Service (NHS) is the largest employer in the UK. In India too, healthcare and its larger ecosystem are an important source of employment.
We have medical colleges and nursing colleges in the public as well as the private sector, and the numbers have seen a significant increase in the last 2-3 decades. But India still needs large numbers of health personnel. We need to enhance their capacity not only in the metros, which are akin to India but also in smaller cities and towns.
Before independence, communicable diseases were a burdening concern, but by providing better healthcare and nutrition, India tackled it effectively. However, now Non-Communicable Diseases (NCDs) are seen as a major challenge in the healthcare sector. It is crucial to devise a strategy from an early stage. Otherwise, we shall lose the advantage of our demographic dividend as many of these NCDs are striking our population in their 30s and 40s. Encouraging regular preventive health checks and keeping control of those with diabetes and hypertension is imperative. An equally critical area is mental health. This is severely underreported and needs to be looked at humanely—with the right infrastructure, people, and processes.
Another callout—as India becomes more urbanised, urban planning must go hand in glove with public health planning. It is unfortunate to see that many urban growth areas lack basic public health infrastructure. We regularly witness the deleterious effects of such gaps in health and urban planning, and we must act on this urgently.
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During the pandemic, we witnessed how the public and private sectors joined hands and collaborated to fight the Covid-19 pandemic. Having been in the thick of things in Odisha during the outbreak, I would like to highlight how Public Private Partnership (PPP) can be put to effective use. Chief Minister Mr Naveen Patnaik foresaw trouble ahead in late March 2020. He put in place a PPP model. Covid-19 hospitals were set up across the state, with the Kalinga Institute of Medical Sciences (KIMS) operating them with CSR funding from Odisha Mining Corporation. 500 beds in Bhubaneswar, 200 beds in Baripada 200 in Bolangir, and 150, in Phulbani—the latter three tribal district headquarters—were put in place.
All hospitals went operational in April 2020 and had wards as well as ICU beds—the Bhubaneswar hospital had a dedicated new 64-slice CT scan to avoid delay in early diagnosis and isolation, even with an initial negative RTPCR report. This was replicated with other private healthcare providers in the state. All Covid-19 patients who required hospitalisation did not have to run around for a bed. All this was done quietly—in a coordinated manner—with Mr Patnaik supervising the efforts himself. PPP has a significant role to play in Indian healthcare. And the public and private sectors need to realise they are part of the same team, not adversaries.
The Right to Health and ways to implement them need to be tempered, keeping the private sector financially viable so they grow, invest and help build our healthcare infrastructure further and stay coordinated with global medical standards.
India’s growth engine needs to run with all working in unison in the spirit of partnership.
The writer is MD, group head – medical strategy & operations at Fortis Healthcare, and former CEO of Kalinga Institute of Medical Sciences, Bhubaneswar.