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India's healthcare system is heavily skewed towards tertiary services which mean that primary healthcare gets neglected. General practitioners and friendly neighborhood family doctors are becoming an extinct species with people preferring specialists.Dr Santanu Chattopadhyay, CEO and MD, NationWide, is a man who intends to change that. NationWide, a chain of primary healthcare clinics looks to bring back the family physician. Excerpts from the interview:
Q: There are a variety of problems that ails India's healthcare system high out-of-pocket expenditure, expensive drugs, and lack of basic service away from urban centers. What in your opinion is the biggest problem with India's healthcare system?
Our healthcare system is focused on tertiary care which means we can treat sick people but don't have a system that looks to prevent that illness or detect critical illness early. People need a hospital only when they are very ill. But good healthcare system should help you prevent that illness and also reduce the cost of treatment when you're sick. To do this, we need to detect problems early. If you take UK's healthcare system for example, everybody has a general practitioner (GP) and they see a GP when there is minor illness and this can help increase screen and prevent critical illness.
Q: Much has been made about the urban-rural divide in accessibility to healthcare services. What can be done to increase healthcare accessibility in rural areas?
We have to understand the constraints on not being able to get all the MBBS qualified doctors to rural areas. The government should make regulations where we can train a set of local healthcare workers and keep updating their knowledge. They should be given good quality training and re-validated every five years and be incentivized to provide better health outcome for local population. Basically, we need to create qualified rural health practitioners who can supervised by MBBS/MD doctors.
Q: How can we decrease out-of-pocket expenditure?
We could try following UK's National Health Service (NHS) model. For example, when I was living there I paid 10% of my income as a contribution to National Insurance. Now this goes into a state fund which takes care of healthcare spends as well. So while I might have visited my GP only twice and spent say 200 pounds of the 20,000 I was taxed. But this helps create a health fund which can be used by anyone and everyone in the community. So while I didn't use my total 20,000 pounds it could have been used by someone else. Another system we can have is a government sponsored insurance scheme which takes care of healthcare spends when the need for it arises.
What we basically need is a system where people are taxed for healthcare services provided by the state. Sadly in India the chances are if such a fund was created it'd probably end up in the wrong hands.
Q: How can technology help in increasing healthcare accessibility in India?
It is a fact that we will not be always able to get a qualified doctor in the rural area. The rural set up does not have the infrastructure. Technology could help address this issue. For example, we can have a trained local population who can be the first point of consultation and then can use video consultation with specialists. But that's very expensive right now and we need to figure out how to make it affordable.
Q: The Government has vowed to improve the healthcare scenario. To this effect the Planning Commission wanted to involve the private sector more. This move was opposed by both healthcare activists and health ministry. Do you think public-private partnership in healthcare can work?
My answer is yes. The whole primary healthcare in UK is private executed but funded by government. Every GP practice there is a private organization to whom the government contracts the service. There is no GP who is a direct government servant. That's the model we should take. The GP gets an annual fee when a patient registers with him. Along with that he gets a success fee depending on health outcome. So the GP would be a private enterprise funded by government. The government pay should be outcome-oriented. Problems start when the government starts executing. Government should be funding infrastructure healthcare, education, road, etc. But execution should be by private. The government should make sure there are technological tools which can measure outcome well and there should be a direct feedback mechanism from consumer to Government authorities. That's the key.
Q: You're a strong advocate for improving primary healthcare. Why is primary healthcare so important?
For this let us compare the healthcare systems of two developed nations the UK and USA. While UK has a primary care oriented system, the US has a more tertiary based specialist system. The UK model says that you first see a primary care physician who suggests a specialist only when it's necessary while the US model sends you directly to a specialist. Various studies have shown that when you've a primary care physician your total healthcare expenses go down by 40% and your hospital admission expenses will go down by 35%.
The specialist driven healthcare is very expensive and often lead to over-investigation and over-treatment and multiple specialists looking at different angles. Whereas in primary care driven model like UK, you will have one person who takes you holistically, tries to find out the most likely cause, manages at that level and refer only when necessary. US spend around 15-18% of GDP and UK spends around 8%. But health outcome in UK is right at the top because of the primary healthcare.
Q: There's a general consensus that GPs tend to refer you to a specialist anyway. So people are directly going to a specialist. What are your views on that?
That's true in India. In UK, 70-80% of day to day illness and serious illness is getting treated by GPs. Only 20-30% gets referred. Whereas in India it's totally reverse. The problem is lack of qualified GPs. While in India a GP is just an MBBS, in the UK a GP needs to undergo 3-4 years of training after MBBS. India has no GP programme. We just have MBBS doctors. Unfortunately education in India is very theoretical. They are not industry based. MBBS doctors can't treat you. So we have to give 3-5 years structured training programme to them and then keep them updated too.
Q: What is NationWide's basic USP? Could you tell us a bit about the company?
Nationwide is a chain of primary healthcare clinics. We have a group of highly trained, patient-centric, ethically practicing doctors. We are also training them, updating their knowledge, giving them a protocol of operating and constantly auditing their performance. NationWide was founded by a group of doctors, well experienced from UK, who understand what it takes to be a good GP, what it takes to train them and how to continuously update their knowledge and keep them patient-centric.
Q: NationWide claims that it will bring back the family physician. How will that help?
The basic unit of primary care is family physician. 30 years ago, the first point of contact used to be family physician. They used to sort out most of the problem and refer as required. People trusted their family physicians and had long term relationships with them. This is exactly what will happen. Here at NationWide, the family physician will be your first point of contact. This will help reduce your trips to the hospital, hospital admission and other medical costs. Healthcare services will be far more comprehensive, if we manage to achieve what we have set out to do.
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