'Better Regulation, Preventive Care:' Healthcare Expert Ratan Jalan On Gaps In The Sector In India

In 1947, the life expectancy of an average Indian citizen was around 32 years. It increased to 70.19 years in 2022. India’s infant mortality rate in 2022 was 27.695 deaths per 1,000 live births, a 3.74% decline from 2021. Progress has also been made in controlling communicable diseases. 

According to the latest World Malaria Report 2021 by the World Health Organisation, only India registered progress against malaria among the world’s 11 highest-burden countries. It was also declared polio-free in 2014 and was running one of the largest leprosy eradication programmes in the world.  India has also made significant progress in controlling diseases such as tuberculosis, cholera, kala azar, and HIV.  

Many government schemes such as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) have also been introduced over the years. While there was a time when private hospitals could be counted on fingers, now large and well-equipped tertiary care private hospitals are mushrooming all over the country. India’s healthcare industry has made many big strides over the last decades. 

However, yawning gaps remain despite the immense progress. Ratan Jalan, the former CEO of Apollo Health and Lifestyle Limited, told The Core, “In the private sector, healthcare is equated with hospital care whereas tertiary care should be the last bastion. Nursing homes or clinics have not been explored seriously as a business. Day-to-day care — the stuff that occupies people’s everyday lives like coughs, colds, virals and so on — does not exist in any organised fashion in the private space.” 

Jalan, who set up the Apollo Clinic Chains as a franchise model and The Cradle Exclusive birthing centre and is an alumni of IIT Kharagpur and Harvard Business School, said that the Indian society pays a heavy price for the lack of preventive and promotive care.  

He said that the government needed to play a bigger role in the prevention of diseases. “The government can do many more public health awareness campaigns and talk about food habits, drinking water or sanitary conditions.” 

Jalan also spoke about other key areas of concern as he sees them and highlighted possible solutions and the way ahead for the healthcare system in India. 

Here are edited excerpts from the interview: 

A lot of progress has been made pre and post-Covid in India’s healthcare sector where the public and private sectors have both played a vital role. What are some of the key gaps you still see?

In the Indian context, healthcare as a business is synonymous with hospitals and that too big multispeciality chains. The nursing homes and other primary care institutions don’t come into people’s minds. 

Healthcare globally or at least in some jurisdictions is much more about primary care as it should be. There is an emphasis on promotive care and on early diagnosis. A lot of focus is on keeping the population healthy like the UK’s NHS. A heavy price is paid by our society for lack of promotive and preventive care. More undetected or late detections of cancers, BP (blood pressure) related problems that spiral, underlying heart conditions that could be easily tackled if caught early enough et al. 

Ironically, this is not even seen as a business in the Indian context. In the private sector, healthcare is equated with hospital care whereas tertiary care should be the last bastion. Nursing homes or clinics have not been explored seriously as a business. Day-to-day care — the stuff that occupies people’s everyday lives like coughs, colds, virals and so on — does not exist in any organised fashion in the private space. 

In the private sector, if you recall, we had family physicians or GPs who came home with their stethoscopes and bags and treated patients for routine conditions like virals, coughs and colds. These are now virtually non-existent. With so much migration happening, this whole concept of family physicians has collapsed anyway.

This adds to inefficiency since this space is not organised. Costs escalate: you might go to a hospital and pay a very high consultation fee for a pretty routine problem like a cold or flu. You have to travel to get there. All these are costs. 

Also, as a result, many people are admitted for problems that could easily be resolved if diagnosed and treated earlier. For instance, there’s no reason for someone to be admitted for treatment of diarrhoea or even dengue but many are. 

Poor primary care leads to inefficiency which leads to higher costs and higher complications. Primary care is not organised across the country so somebody in Malabar Hill faces the same problem as someone in rural Bihar. The Bihar patient may need to travel 30 kilometres to access quality care and the Malabar hill person may be forced to experiment: try one doctor, if it doesn’t work, try another and so on. 

At a public level, government primary healthcare centres exist but often doctors, nurses and basic facilities at these centres are missing and people receive a very low quality of care if at all. In many rural and even small cities, the system is so broken that the population just suffers; they don’t have access to any healthcare. This also adds to the burden of diseases a society carries.

There are very wide state-level variations in primary health care centres one finds. 

That is true and appears to be directly correlated to what the citizens of a state demand and expect. To that extent, the citizens see to it the system works. So, these might function better in say Kerala or even perhaps Goa while in states like Bihar, there is 100% tolerance for everything: things don’t work so they don’t work and everyone accepts and moves on. 

There appears to be a lack of political will and accountability at the political and bureaucratic level: we are cognizant of the fact that India’s health budget is inadequate, yet there are many states that fail to exhaust even the existing low budget amounts. From what I hear, the health ministry is viewed as a punishment posting.

The problem here I think is that the political dividend of providing high-quality healthcare is not yet evident to all. Unlike education, the benefits of good healthcare are felt immediately. To some extent, the clinics provided by AAP in Delhi — which some other states have been trying to emulate — have yielded results for them.

To get back to the primary healthcare point, I don’t think this would excite the hospital chains in the private sector. Hotels will not get into the restaurant business for instance. Primary healthcare is very retail, small transactions, high volume. It is a very different business from the hospital space. It needs a different set of players to jump in and get excited about this market. Hypothetically, a Tatas or a Reliance could do it or even one of these new well-funded startups. In five years, I wouldn’t be surprised if a player like Amazon or Google who understands scale and the wide variations of this country does it.

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But this would require even more regulation, which is a weak spot already.

This brings me to one of the biggest concerns I have. Today the government looks at its role more as a financier of health schemes. This does address affordability but the government’s role has to be much wider.

The government can do many more public health awareness campaigns and talk about food habits, drinking water or sanitary conditions. We had done a pilot on these in Saharanpur, Munger and some other areas and our takeaway was that there’s nothing like more awareness of living conditions to check the spread of infection and diseases. This is where I think the government can play a bigger role. As of now, initiatives on this front have tended to be a bit superficial.

Further, regulation in India is very knee-jerk. So if one patient dies and there’s an uproar over his or her treatment or mistreatment or an unexpectedly bloated bill, just one stray incident and the government will say let’s close down this hospital or facility. The approach is very knee-jerk and not systemic. 

Let me cite a few incidents. For instance,  if the AMRI fire was a wake-up call, you and I don’t know what is happening to the fire safety norms at hospitals or similar facilities across the country. Are we much better off today or are we at the same spot? Children die due to lack of oxygen at a hospital. It was Nashik yesterday and it is Gorakhpur today. Even when one comes across such crises repeatedly, we find there is no systemic response. 

To take this a step further, we don’t even know if hospitals in smaller towns and cities, places not right under our noses, have quacks or credible practitioners. There may be 40,000-odd pathology labs in the country. People give their blood and get a report but you and I have no idea what is really happening inside that lab.

Mind you, I’m not saying it’s all bad news. This growing trend of large hospital chains getting into smaller towns and cities - which has been around for a while and may be more pronounced now - is good since in Covid, many patients availed of services in their own hometowns and actually got the level of service they required. The myth that good healthcare is available in only the big metros was busted to an extent. It is really unfair for people to travel 300/400 miles for a heart surgery or knee replacement and I think this decentralisation or declustering of healthcare is both desirable and necessary.

I can’t imagine this even in the next 50 years. We function in a very haphazard manner and what you are asking for sounds more like an ideal world.

I think even if we settle for a system of self-declaration to begin with, it will constitute progress. Some basic norms that a healthcare provider needs to follow and declare it is following might be the first step. Then after this happens, the system needs some degree of inspection. This is equally true for the public and the private healthcare providers.

Isn’t the rising cost of healthcare at private hospitals a concern today too? We constantly hear about overcharging by providers… and what can be done to ensure we don’t go the American way in this aspect? 

The good news is that post-Covid in particular, the sector has got enough interest from investors and there is therefore plenty of money available for the private sector to expand and grow. The best that can happen is that more and more hospitals will put some downward pressure on prices but on the other hand more and more investment will push for higher returns or find ways to charge more. Doctors in corporate hospitals are not incentivised to be conservative since he or the hospital earns by doing more, not less. By design, they are aggressive.

Only the regulatory framework can check this. At the moment, insurance companies do this to an extent: if you are not charging as we think, we will disallow certain expenditures but at a government level it is still knee-jerk. Suddenly someone will get up and say we’ll put a cap on stent prices or some such. There is no thought-out response.

The only good news is that technology will be the biggest disruptor. More and more wearables (devices that help monitor health parameters) and ease of diagnosis and monitoring will make us less helpless and less reliant on the doctor as the last word. A sense of control will come in. I know what is happening to me. This shift I think is going to happen.

As far as the American system goes, I think we are quite far from where they are currently simply because insurance penetration is very very low in India. Almost 25 years ago, this professor at Harvard put it to me: that in any industry where somebody else pays for what you consume, the consumer becomes indifferent to what is being charged and the provider will charge you more and more. This is the problem for the US where the level of insured population is very high. So if I as a consumer know that the chances of success of a surgery or treatment is 8% and it costs a million dollars, I still want it. We are quite far from that as we don’t have the luxury of unlimited funds and budgets and our insurance penetration is still low.

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