The current case once again brings to light the countless flaws in the prevailing Indian healthcare system that is plagued by shoddy practices, including unavailability of proper infrastructure, along with the callousness and disenchantment of the medical practitioners and the staff in general both towards the medical profession and the patients, that manifests itself into decreased morale and increased turnover and absenteeism rates amongst them. With the needle this time pointing towards SR Hospital, a middle-class government hospital in Kerala (India), the case tries to briefly talk about the current financially debilitating state of the medical establishment, which again is an offshoot of the sick and crippled Indian healthcare set-up. An attempt has also been made to identify any scope for improvement in the overall functioning of the system using various management interventions so as to make the working environment mutually beneficial both for the employees and patients.
Healthcare in India - Current Scenario
Frequently touted as one of the strongest pillars of the Indian economy with an enormous growth potential, the healthcare sector is a proud entrant in the premier league comprising of some of the largest fastest growing sectors on which India’s economic system heavily relies on, both in terms of revenue and employment, as evident from its annual growth rate of “16% in the 1990s valuing it at $34 billion in 2007” (PricewaterhouseCoopers, 2007). As per Fitch Ratings, today, “the industry stands tall at $65 billion, all poised to catapult itself to a $100 billion valuation figure by 2015, galloping at around 20% annual growth rate” (Overseas Indian Facilitation Centre , 2012). A number of factors have propelled growth within the sector, prominent amongst them being “ever increasing population, spurt in lifestyle-related ailments such as diabetes and hypertension, cheap medical treatment, thriving medical tourism, improved health insurance penetration, increasing disposable income and proactive government initiatives including emphasis on promotion of Public Private Partnership (PPP) Models” (Overseas Indian Facilitation Centre , 2012). An impetus to this growth has been provided by the Government of India, “ which has decided to increase the expenditure on healthcare from the existing figure of 1.4% of GDP to 2.5% as part of the Twelfth Five-Year Plan (2012-17), as directed by the Prime Minister, Dr. Man Mohan Singh” (Overseas Indian Facilitation Centre , 2012).
The facts revealed so far definitely point towards the aggressiveness in pace surrounding the proposed positive developments in the field of medicine and healthcare in India, all of which in the near future would only help the BRIC economy member earn the reputation of a leading provider of cheap and quality healthcare in the world. However, all this glitterati represents only a macro-level view of the picture, with the micro-level bird’s eye view being ugly and hard to face.
In reality, the Indian healthcare industry is highly fragmented, with its reigns totally in the hands of the private sector, comprising of existing large corporate hospital chains as sources for influx of huge capital investments” (MEGStrat Consulting, 2012) , leaving the government set-up behind. This is evident from “its growing contribution in the total healthcare expenditure up from 60% to 80% over the last ten years” (People Matters Media Pvt. Ltd., 2012). Further, “challenges also exist with respect to service accessibility especially in far-flung rural areas and even Tier II & III cities along with low quality patient care provided by the government-run facilities due to inadequate healthcare infrastructure and medical equipment. For example “the SR General Hospital in Akuthumuri, Varkala (Kerala), a 100-bedded hospital was established in 2007 under the Management of the SR Educational and Charitable Trust as part of the Sri Sankara Dental College, and affiliated to the Kerala University of Health and Allied Services” (Sri Sankara Dental College). Being charitable in nature, the set-up at present caters mostly to the needs of the general public at a negligible cost, admitting over 15,000 patients and conducting nearly 10,000 ambulatory visits, annually. This means 0.01 beds per thousand patients, leave aside 15,000 of them, straightaway pointing towards under-utilization of the existing capacity, which is definitely an infrastructural issue to deal with. Unfortunately, not just one small district within the State of Kerala, but the entire country is full of such harsh realities. “In its 2008 report, Ernst & Young unravelled another face of India’s hidden and untapped healthcare potential by saying that it has 0.7 beds per thousand patients, in contrast to the world average of 2.6, a figure, shrunk by the industry insiders to 1.5 beds per thousand currently”(People Matters Media Pvt. Ltd., 2012). This “not only confirms an acute shortage of healthcare infrastructure in India, but also signals the demand for “additional 1.75 million new beds by the end of 2025” (MEGStrat Consulting, 2012).
The healthcare facilities in India also suffer from budgetary constraints, springing from inadequate investment of funds, “as evident from a 2008 study that revealed that the healthcare expenditure in India was almost 50% of the global average spending in terms of the ‘% age of GDP’, which is significantly lower” (MEGStrat Consulting, 2012). This, apart from taking a toll on the quality of facilities and services provided also hurts the pocket of the medical practitioners, whose salaries fail to cope with the rising cost of living, thereby, making them earn quite less in comparison to their counterparts working either in big private corporate hospitals or running their own private clinics. This results in loss of morale and enthusiasm at workplace, triggering increased attrition rate and absenteeism amongst the doctors as well as other medical and non-medical staff.
Apart from healthcare set-ups and facilities, this problem of insufficient funding is also slowly penetrating into the academic domain, with “inadequate finances to fund both medical and nursing education and training, thereby, further plunging India into human health resources shortage crisis, revolving around poor quality of medical care in the public and government hospitals like the SR Hospital vis-à-vis the private ones” (Rao, Rao, Kumar, Chatterjee, & Sundararaman, 2011).
Finally, analysing from scratch, we opine that both infrastructure and budget represent issues whose resolution would only provide a structural alleviation by mending the overall healthcare system. However, at the end of the day, it is the human resources employed by the facilities, who would be ultimately driving the show. Therefore, this discussion would remain incomplete without a close scrutiny of the various human resource problems or issues that underlie the Indian healthcare sector, since “healthcare unlike any other industrial sector is fairly complex in terms of its nature of work which cannot be neither be easily predicted as it involves the crucial matter of life and death and nor can it’s outcomes be easily assessed using profitability as standard benchmark due to the underlying dual lines of accountability both towards the medical profession and the country’s administrative set-up, thus, making Human Resources Management in a hospital much more challenging and daunting to carry out than in a bank or a hotel” (Agarwal, Garg, & Pareek, 2011). Some of the key human resource issues restraining the healthcare set-up in India from blooming optimally are discussed below.
Firstly, “the prevailing recruitment system meets only the basic requirements of correctly assessing the eligibility of the candidate based on formal academic and professional credentials, failing to evaluate them beyond that point for presence of soft skills dimension of personality comprising of communication skills, ability to tolerate stress, conflict management, negotiation skills etc.. which are equally important since the doctor would be dealing with human beings like him/her” (Agarwal, Garg, & Pareek, 2011).
Secondly, at present, “the country’s health workforce composition is convoluted with both qualified and unqualified individuals and quacks, providing diverse range of medical services, often without proper professional training” (Rao et al., 2011), especially in the rural areas, where lack of education and pre-existing widespread ignorance prevents the people from differentiating mere ‘lip service’ from correct diagnosis and treatment.
Thirdly, even after being inducted in the hospital, the new hire gets a work environment that instead of increasing his job satisfaction level, tends to decrease it. This is mostly the case in government hospitals, having a shoddy nepotistic recruitment system, lack of thrust on re-skilling and training initiatives, “clandestine and subjective performance appraisals, devoid of any objectivity in terms of clearly reflecting the individual’s capability and quantifying his output indicators, and even lack of logically visible and concrete relationship between rewards and performance, which are no more than salary raises and promotions, that too mostly based on seniority and other non-performance related factors, that tend to kill the inner desire and motivation of the person to perform the job, thereby proving suicidal for his physician-patient relationship, which is based on intrinsic happiness and willingness of the healthcare provider to serve the patient ” (Agarwal, Garg, & Pareek, 2011). This is evident from a research study conducted to “assess the job satisfaction levels of 250 healthcare service providers, which included 100 doctors, 50 nurses and 100 paramedics i.e. both pharmacists and lab technicians, working in CGHS (Central Government Health Scheme) Dispensaries in Delhi that represents one of the biggest public health organizations in the country catering to a huge section of the organized sector. The results obtained based on an interview of the participants highlighted low job satisfaction levels being experienced by them” (Bhandari, Bagga, & Nandan, 2010).
Healthcare Reforms - Proposed Solution
Considering the labor-intensive nature of a physician’s job and the very complexity surrounding it owing to the critical matters of life and death he/she handles daily, calls for bringing about an organizational change in the healthcare set-up through implementation of reforms and policies in an organized fashion that would improve the overall quality of healthcare outcomes.
Firstly, “a socio-technical systems design” (Heine & Maddox, n.d.) needs to be implemented, whereby, both the physician-physician and physician-patient relationship throughout the set-up, which in most cases goes missing behind the bogus administrative rules, treatment procedures and multiple hierarchical levels, improve, resulting in “more teamwork, communications and improved patient delivery in all areas of hospital operations”(Heine & Maddox, n.d.). However, in doing so, “care needs to be exercised in preventing the hospital culture and practices, normally comprising of status differences, amongst providers, along with the personality differences amongst them with respect to using a particular surgical or treatment practice, from hindering improved quality service delivery and unit interpersonal communications”(Heine & Maddox, n.d.).
Secondly, “having witnessed a transition from being a planned economy to a free market one, the Indian government needs to be proactive in implementing health policies aimed at improving the reach of the healthcare services, especially to the socially and economically deprived, at a subsidized cost, while bravely battling the tight fiscal constraints that come along with this transition, as implementation challenges, in the form of low health indictors and limited financial resources, in comparison to the advanced economies at a global level” (Rudraswamy & Doggalli, 2012).
Thirdly, “product innovation in the existing portfolio of health insurance products that currently offers limited services and reimbursements along with lack of coverage for pre-existing conditions and outpatient expenses is required, so as to provide a more comprehensive coverage for income classes, age groups and alternative therapies. However, the challenge lies in creating a regulatory environment that recognizes health insurance as distinct from other lines of business in order to spike up the sector’s growth” (Gupta, 2008).
Fourthly, quality healthcare education both for the public and physicians cannot be ignored and would require full-fledged support of the government in the form of “setting up of medical colleges and super specialty tertiary care hospitals with research and education centers throughout the country, especially in remote areas to benefit the masses” (MEGStrat Consulting, 2012). “Further, for a country mostly reacting to control diseases instead of preventing their occurrence, a paradigm shift in thinking towards awareness of prevention is definitely one of the most critical components of reforms. The challenge that needs to be addressed in doing so pertains to illiteracy amongst majority of Indians who still don’t realize the importance of preventive measures, that are crucial to avoiding lifestyle diseases, and thus, difficult to educate about health priorities” (Gupta, 2008).
Finally, though the rural outreach of the healthcare sector is definitely a much emphasized goal, but the complete success of the healthcare reforms lies in its promise to help urban Indians too who also experience severe health disparities. “In pursuit of this objective, the Seattle Indian Health Board hosted an Urban Indian Health Summit on January 13, 2011 in Washington D.C., wherein a Call for Action containing the following insights and recommendations for federal partners to ensure success of healthcare reforms for urban Indians was formulated” (Robert Wood Johnson Foundation, 2011):
Workforce development in the form of strengthening existing and new resources for providers willing to serving urban Indians through continued support and encouragement in the form of alliances with National Health Service Corps and other manpower training programs to address unmet service needs.
Actively recognizing those urban Indian health organizations that are Federally Qualified Health Centers as a solution to the shortage of primary healthcare as ‘essential community providers’.
Understanding the complexities and implications of the Patient Protection and Affordable Care Act (ACA), critical for the successful implementation of healthcare reforms for urban Indians.
Awareness regarding the technicalities involving Medicaid & Medicare provisions that could pose as impediments to successful reform implementations, such as ensuring availability of timely support and technical assistance to the urban Indian health organizations with respect to becoming involved in health insurance exchanges.
Strategically positioning the urban Indian health organizations to make the best of healthcare reforms.
Developing partnerships and liaisons with local, regional, and national bodies to ensure timely availability of opportunities to the urban Indians.
The Road Ahead
Given the current state of affairs, though the Indian healthcare sector in India has come a long way with significant advancements, ever since the country attained independence in 1947, but yet, a lot needs to be done, making us view the entire set-up as a glass both half empty and half full. We point towards the creation of an “Integrated National Health System to achieve complete healthcare for all Indians by 2020, as suggested by Reddy et.al. (2011) in their article published in the Lancet Journal through the fulfilment of the three important goals of ensuring a complete pan-India quality healthcare service delivery by scaling up the existing healthcare infrastructure through pumping of additional investments; reduction of financial burden of healthcare on individuals by increasing public spending on health which would decrease their out-of-the pocket health expenditure from 80% to 20%; and finally empowering people, especially the rural population to manage their health by educating and training them and making the entire healthcare set-up accountable for their actions through regulation of suitable governance in the form of having formal mechanisms in place to make the components of the National Health Bill, 2009 and similar legislations, functional.
At the same time, a proactive effort also needs to be made for decentralizing the country’s entire healthcare set-up by making both the public-private healthcare entities work in tandem so as to resuscitate the system, by devising new ways to establish, strengthen and sustain their new found collaboration commonly aimed at improving the effectiveness and efficiency of the healthcare outcomes in the country.
Finally, we would like to end this discussion by reiterating the fact that though on face value, such proposed ideas or changes may seem simple, but deep down it requires a great deal of commitment and sustained level of hard work on the part of all stakeholders involved to implement and crystallize them, but once successful, we can be rest assured of their long-lasting efficacy to not only invigorate and empower the workforce and administration in the healthcare industry, but also inculcate within them a feeling of self-direction and motivation to continue treading this shown path without any external guidance or support. Apart from that, the widespread feeling of status consciousness currently prevalent in the work culture of the hospitals would also be toned down as a result of the success of such planned actions, since it would cause all the professionals regardless of their academic and professional stature to willfully strive for attaining positive health outcomes for patients, keeping their personal differences aside and instead using synergizing their professional expertise to deliver their best results.
But, as mentioned before, like all historical changes that have passed through the prevailing political, legal and administrative set-up of India, these too would be no different, and thus, their success, for the most part would depend on the willful support of the above mentioned facets of the country’s changing environment.
Agarwal, A., Garg, S., & Pareek, U. (2011). Strengthening Human Resources Practices in Healthcare in India: The Road Ahead. Indian Academy of Clinical Medicine, 12(1), 38-43. Retrieved from: http://medind.nic.in/jac/t11/i1/jact11i1p38.pdf
Bhandari, P., Bagga, R., & Nandan, D. (2010). Levels of Job Satisfaction among Healthcare Providers in CGHS Dispensaries. Journal of Health Management, 12(4), 403-422. DOI: 10.1177/097206341001200401
Gupta, R. (2008). A Healthier Future for India. Retrieved from http://www.gken.org/Docs/A%20Healthier%20Future%20for%20India_rajatgupta.pdf
Heine, R. P., & Maddox, E. N. (n.d.). Hospital Management Reform: A Step to Healthcare Reform. Journal of Management and Marketing Research, 1-7. Retrieved from: http://www.aabri.com/manuscripts/10443.pdf
MEGStrat Consulting. (2012). Indian Healthcare Sector: A Galore of Scope and Opportunity. Gurgaon: MEGStrat Consulting. Retrieved from: http://megstrat.com/reports/HealthCare-India/Indian-Healthcare-Sector-Report-MEGStrat-Consulting.pdf
Overseas Indian Facilitation Centre . (2012). Healthcare in India. Retrieved from http://www.oifc.in/Sectors/Healthcare
People Matters Media Pvt. Ltd. (2012). Industry Focus: Indian Healthcare Sector - A Healthy Dose of Success. Retrieved from http://peoplematters.in/articles/industry-focus/industry-focus-indian-healthcare-sector-a-healthy-dose-of-success
PricewaterhouseCoopers. (2007). Healthcare in India: Emerging Market Report 2007. Retrieved from http://www.pwc.com/en_GX/gx/healthcare/pdf/emerging-market-report-hc-in-india.pdf
Rao, M., Rao, K. D., Kumar, S. A., Chatterjee, M., & Sundararaman, T. (2011). Human Resources for Health in India. The Lancet, 377(9765), 587-598. DOI: 10.1016/S0140-6736(10)61888-0
Reddy, K. S., Patel, V., Jha, P., Paul, V. K., Kumar, A. S., & Dandona, L. (2011). Towards Achievement of Universal Healthcare in India by 2020: A Call to Action. The Lancet, 377(9767),760-768. DOI: 10.1016/S0140-6736(10)61960-5
Robert Wood Johnson Foundation. (2011). Actualizing Healthcare Reform for Urban Indians . Seattle: Robert Wood Johnson Foundation. Retrieved from: http://www.uihi.org/wp-content/uploads/2011/06/Actualizing-Health-Care-Reform-for-Urban-Indians-Report.pdf
Rudraswamy, S., & Doggalli, N. (2012). Health Policies in Transition Economics. Journal of Hospital Administration, 1(1), 1-7. DOI: 10.5430/jha.v1n1p42
Sri Sankara Dental College. (n.d.). SR Hospital. Retrieved from http://www.srisankaradentalcollege.com/sr_hospital.html