This is the third post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we explore innovative healthcare delivery models emerging from the private sector, and how they might fit into government goals of achieving UHC and comprehensive PHC.
India’s immense socioeconomic, ethnic, epidemiological and demographic diversity creates fertile ground for innovation, and this holds true in the healthcare sector. Much has been written on healthcare innovators and novel technologies emerging from India. While the focus tends to be on affordable medical equipment, therapies and information and communication technologies, outside of the spotlight, some private healthcare organizations are unleashing pioneering delivery models to provide basic care to the poor. For our purposes, a delivery model is merely the ways in which care is provided to a person, population group or patient cohort. Understanding the roll-out process, costs and impacts of these innovative delivery models is important in light of government goals to progressively achieve UHC and to strengthen primary healthcare.
Currently, most healthcare in India is of an on-demand, curative nature, and is primarily provided by hospitals and private practitioners. This is especially the case in the ambulatory market. On one hand, public ambulatory facilities emphasize disease-oriented vertical programs and RMNCH services. On the other, private providers, who deliver over 70 percent of ambulatory care, operate on a fee-for-service basis and have few incentives to move away from the prevailing episodic model of care. Yet the changing burden of disease in India, coupled with rapid aging and urbanization, necessitate a new model in which primary healthcare takes a foundational role and there is close and regular interaction along the continuum of providers, including hospital-based professionals, primary care providers, community health workers and home care providers. Recent government directives are taking first steps toward developing such a model with an emphasis on comprehensive primary healthcare, aligned with global best practice. However, government focus tends to be inward – limited to the public delivery system, which is a relatively small player in the healthcare delivery landscape – rather than looking more broadly at the sector as a whole, and learning from innovative non-profit and for-profit players across India.
The private sector has implemented different types of delivery models that generally aim to provide high-quality, affordable care to those at the bottom of the pyramid. For example, the non-profit CARE Rural Health Mission, which operates in Andhra Pradesh and Maharashtra, is one of many leveraging telemedicine to link trained community health workers with remote physicians at primary care clinics and hospitals. This approach helps to circumvent India’s acute shortage of trained doctors and nurses. In Mumbai, the for-profit Swasth India Medical Center (SIMC) runs a chain of health centers in the city’s slums. Its clinics provide much needed access to drugs, prevention, primary care, dental and diagnostic services, and facilitate referrals to hospitals and specialist as needed. Through smart procurement and efficiency gains from digitized patient records as well as use of standard protocols and referrals, SIMC reportedly offers affordable prices and achieves high patient satisfaction. There are numerous other examples of similar small-scale efforts with potential for scale-up.
These examples embody the novel approaches being tested at the state and district levels as private organizations employ inventive techniques to deliver reliable, lower-cost healthcare. Yet, for all the successes, there have also been failures. E Health Points, a hub and spoke care model leveraging digital technologies and task shifting in rural Punjab, reportedly is no longer in operation Why was it unsustainable, and why have other models with similar features succeeded? Moreover, do these organizations have the performance and capacity to be contracted under the government’s PM-JAY insurance scheme to deliver a primary healthcare package to support expanded access? We don’t know.
With the exception of highly touted models such as the chain of Aravind Eye Hospitals and Narayana Institute of Cardiac Sciences, which provide specialty care for specific conditions, most of what is known about private sector delivery models focusing on the bottom of the pyramid is from landscape mapping exercises (see here and here) and descriptive case studies. Though valuable for raising awareness and introducing policy makers to these innovations, they lack details on performance, implementation processes and potential for scale-up. Without such evidence, it is difficult to replicate successes, inform policies or plug into government efforts to effectively expand coverage. The lack of evidence may be due to resource limitations and lack of capacity of these organizations to measure impact.
These information gaps echo the data and measurement challenges innovators and social entrepreneurs face elsewhere. There needs to be a greater research and policy focus on understanding the “why”, “how” and “so what” behind India’s many innovations in healthcare delivery models, rather than just documenting the “what”. This will put government in a better position to adopt learnings and locally-tested best practices in support of its policies for UHC and comprehensive primary healthcare.