As you’ll have seen from Twitter the first country I’ve travelled to for the fellowship is India. I owe Dr Parag Singhal, Consultant Endocrinologist at Weston NHS Trust and National Secretary for BAPIO, the British Association for Physicians of Indian Origin, for making the introductions that made this trip possible. Thank you Parag!
Before going I’d read up about healthcare and I’d particularly recommend Mark Britnell’s book In search of the perfect health system. If you have a limited attention span like me its brief chapters provide an ideal introduction to each country’s health system including its challenges and innovations. The picture below was taken whilst re-reading it whilst stuck in an epic hour-long Delhi traffic jam.
In order to get an insight into what people think about healthcare I ran a focus group in Delhi with a group of students and professionals thanks to the amazing Delhi Toastmasters club. I have to say I was blown away by the passion the group had in discussing healthcare – a seriously impressive bunch! The four themes I picked out from this focus group which I’ll explore further were: equity, sanitation, prevention, and resources and organisation.
Britnell’s India chapter is entitled one country, two health systems and this was clearly evident from discussions and (as you’ll see in my next blog) in visits to hospitals. Bharat in the focus group described the inequity between excellent private provision that is available to the richest part of society compared to little or no healthcare available to those uninsured. He said “what you call a birthright in the UK may not be a birthright here because everyone doesn’t have medical insurance”. In fact only about 10% of Indians have any insurance and healthcare is the leading cause of people falling back below the poverty line with families often having to sell their property or possessions to fund what they need (see here for stats and current government plans to address this). This inequity is also split between cities and the countryside with medical facilities largely centralised to urban areas meaning little provision is available in rural areas.
Numerous people discussed the importance of sanitation with me and emphasised both how important this was but also concern that it wasn’t improving. I recognise my sample was biased being largely urban but there was a lot of concern voiced about poor sanitation, let alone healthcare, in rural areas. According to the World Bank over 300,000 children a year die from diarrheal diseases and a whopping one in ten deaths in India are due to poor sanitation (See the economist for a good summary here). Whilst driving between cities I saw people queuing to collect fresh water from lorries as we were in the middle of an acute water shortage (see Reuters article here).
Discussion of healthcare in the UK is often based around hospitals with typical questions focusing on do we have enough beds, doctors or nurses. My discussions in India were significantly different with the majority of discussion not focusing on treating ill people but on the importance of prevention. A number of people highlighted the impact they’d seen from the Bill and Melinda Gates Foundation in reducing infectious disease particularly in poorer states such as Bihar (for a good summary of their work see here). In the focus group there was a great deal of discussion about attitudes to early diagnosis and the fact that there were minimal check up programmes to identify the early stages of disease. In a discussion about cholesterol for example, Yagit talked passionately about how “the first time people find out they have high cholesterol is when they have a heart attack”. The group also discussed the importance of price as a disincentive to seeking early diagnosis with one explaining that unless check ups were free, people would be unwilling to seek help. This made me reflect on the discussions often raised in the UK about introducing payments to access ED or GP appointments. The issue of price discouraging preventative healthcare for those with little funds is real.
Resources and Organisation
I’ve grouped these two as they were always connected when I discussed levels of funding in India. Before going to India I expected it’s incredibly low health expenditure to be a prime topic of conversation. India currently has public expenditure of just 1.2% of GDP on healthcare making it one of the lowest funded systems in the world. With the UK already struggling with around 9% compared to many European countries at more than 11% (see this article for a good King’s Fund summary of health funding) I thought this would be highlighted as the key issue that needed to be solved. I was seriously mistaken. I reckon only about half of people I spoke to saw the funding level as an issue at all. People often referred to there being not enough doctors but didn’t link this to funding. When I pushed people the response I often got was “of course we need more funding, but the most important thing is a clear strategy/a primary care service/better sanitation”. Instead of funding the key point made was there was a need for a clearer and more focussed strategy to improve healthcare across India, improve prevention and tackle inequity. Despite having read about the current government’s health reforms (summarised here), many of those I spoke to felt that health strategy needed a stronger central direction to improve things such as standardised and affordable pricing and the development of a comprehensive primary care system.
These discussions made me rethink my beliefs around Indian healthcare but also about health more generally. Coming from what I increasingly recognise is a hospital-centric system it was eye-opening to see discussions so focussed on public health and equity. It made me recognise firstly that we are lucky to have such an equitable system with some great achievements in preventable disease in the UK. But it also made me reflect that we need to focus more effort and funds on prevention rather than just treatment.
Finally, as I had a day spare in Delhi decided to do a short walking tour to see some of the sights. This was a serious mistake for a soft British person – at the middle of the tour temperatures reached 47 degrees and I thought I might pass out as I lumbered down some steps. While I was thinking this, a man ran past me carrying what I saw was a 100kg bag of spice. I was in total awe of the resilience and strength of people working in such conditions but also recognised the unique health context posed by such extremes. I’ll post some videos from the focus group over the next few days. Next week’s blog will focus on Max Healthcare – one of India’s leading private healthcare providers.