Save the Histrionics, Help the Girl Child

This January, India shall mark the first anniversary of the “Beti Badhao Beti Bachao” campaign. The laudable effort of the Government, led by the Prime Minister’s clear message to educate our girls and ensure their safe upbringing was indeed the message India needed. India has had the terrible misfortune of suffering from the bane of female infanticide. A whole host of reasons – ranging from literacy levels, to lack of women’s safety amongst others have been given for why we, as a society, witness this modern day cold-blooded murder. Therefore, the Prime Minister’s clarion call for a concerted attempt to correct this malaise in our society was timely.

While we all acknowledge the importance of this campaign against female infanticide, the facts that have emerged on India’s sex ratio in the 2011 census makes for mind numbing reading. India today has the lowest sex ratio since 1961. From a level of 927 females per 1000 males, the figure in 2011 stands at a dismal 918. Further, the decline in females has been witnessed most notably in the Hindu population, which form a majority in our country. Proponents who argue on a direct link between the lack of literacy and skewed sex ratios would do well to look at the census data. While overall literacy a rate across communities in India has risen, the effect on sex ratio has not only not improved, but declined further. The only proverbial silver lining seems to be that as compared to the previous decade’s census, the literacy rate amongst women has risen notably. So while there are not enough girls for a healthy society, at least more girls are going to school. Cold comfort for 21^st Centaury India I am afraid.

The situation in India that emerges today is not a pretty one. It’s one that needs drastic and collective action as a society. Those of us who propose increasing levels of literacy are not far from the solution, but more needs to be done on multiple fronts. Many parents see a girl as a “burden” (I put the word in quotes because I abhor the notion). This stems from a belief that the money spent on rearing and educating a child is better spent on a male child than on a girl. This cruel ‘return on investment’ myth needs to be demolished. Not only are educated women more likely to create stable and prosperous households, they will also educate their children further than illiterate mothers. Educated mothers and wives help create healthier families and also contribute meaningfully as equals to the household monies.

The Government therefore needs to attack this problem with a multi-pronged approach. To begin with the Government has taken important steps in curbing the menace of ultrasound machines being used in an unregulated manner that has directly contributed to the skewed sex ratio in India today. This needs to be further strengthened given that one hears incredulous stories of ultrasound machines at veterinary clinics being used surreptitiously for screening pregnant women at the behest of desperate to be parents. The Government needs to incentivize the investment in the education and upbringing of girls. While free education is today offered as a universal policy, access to quality education and to means of reaching these institutions is important. Some states have adopted the distribution of bicycles as a means of ensuring that freedom. Also important are education and awareness campaigns, which need to percolate down to the village and mandal level. On the last count, the Government has done well.

But most of all, we as a society cannot expect the Government to cure the ills that we create. Ultimately, we all have to set examples and ensure that we make others more aware of the problem India faces. It is time we practice what we preach. Parents of girls should not fear for the safety of their children as they live their lives as free citizens of India. This entails not only better and effective law enforcement, a change in mindsets and awareness; it also requires a will. The time for inaction is over. The time for candle light marches is also over. 21^st Century India carries an 18^th Century scourge; we must all do our utmost to tide over this. As a proud father of a beautiful five-year-old girl, I just hope that when one reads the Census of 2021, I can be proud of what we have collectively achieved. With this hope I welcome a new year.

Healthy Voices - What patients expect from its health system

The Government and the health sector have been engaged in a sustained dialogue on the future of Indian healthcare and the course that should be charted for it. With the new Government in place at Raisina Hill, the question on the minds of health policy makers, industry bodies, analysts and providers is how to create a 21^st century health system that is accessible, equitable and affordable. Endless debates have been witnessed at meetings, symposiums and conferences on what should be done to achieve the hallowed aim of health for all. While the debate and discussion rages on, it is often intriguing to note the lack of focus in these forums on asking a fundamental question – what does the patient expect and want?

Health services, like all services, need to be designed and aligned to the needs and wants of the end user and consumer. In case of healthcare, the end user is not a homogenized demographic, but rather a heterogeneous mix of populations that have great socio-economic, geographic and cultural divides. Therefore, the question of what the end user of health services desires is often left inadequately answered at best and unanswered at worst.  Having worked in a large healthcare institution that provides for a wide section of the urban and semi-urban population, one can summarize some of the key wants of our end users as follows.

Access and Accessibility

Accessibility to health services finds mention in all discussions on healthcare. However, the definition of accessibility to health services has been too closely tied down to mere provisioning of services. While provisioning remains key to accessibility, many a times having infrastructure and trained manpower is not enough to access care. The availability of doctors, their attitudes towards patients and relatives and the availability of key medicines and adequate education is key to what patients expect out of the health system. Both in public and private provisioning, patients with access to doctors often complain about their inaccessible and paternalistic attitudes towards them and their plight. The need for empathy is being felt even more acutely in a fast changing and rapidly technology driven health system.

Transparency

Patients often find the health system, its navigation, their treatment planning and payment structures opaque, obtuse and bewildering. The advent of health insurance has been a boon to ensuring access to quality health, as has been the introduction of health IT in billing and data management. But these systems have also made the understanding of how treatments are planned and paid for confusing. Patients expect hospitals and providers to do a better job of explaining costs, payments options and help in better financial planning for their medical condition. Hospitals – both public and private would do well to lay more emphasis on being more transparent and help their patients in navigating their services as a partner rather than a “mere” user of services.

Cost-Effectiveness

With rising costs and increased out-of-pocket spending for health services, patients have become more demanding of cost-effective options for their conditions. The previously held logic of expensive treatment being more effective has now been replaced with a cautious consumer of medical services who questions each modality, weighing the benefits, both in terms of costs and outcomes. Hospitals and providers must ensure that out of the range of options available, patients are made to understand the reason for why a particular treatment was chosen over another.

Trust

Hitherto to the ushering of modern healthcare in India, trust was considered sacrosanct and inherent for doctors. The virtual deification of medical professionals was a primary motive for young Indians to aspire to become doctors in the first place. Regrettably, the past decade has seen a gradual erosion of that previously held exalted positioning of doctors. Doctors and associations often feel unfairly targeted by a judgmental media, often misleading information on the Internet and patients who judge their providers with suspicion. While some of these notions are no doubt unfair and monolithic in their construct to describe an entire profession, the acts of a few in the profession have led credence to the reason for distrust. Doctors, associations and hospitals must do more to win back the trust of its patients through ethical and transparent practices which will help create a new age for doctor-patient dynamics. Adequate communication also plays a key role in enabling a more trusting environment, an often-overlooked aspect in the trust paradigm.

Affordability

When asked, most patients and their families’ unhesitatingly express their willingness to spend money for quality care. The expectation of free but inadequate care is thankfully a thing of the past. Citizens are happy to pay a user fee for public services, including in health, provided that quality remains uncompromised. Having said that, rising costs of healthcare have been an area of concern that needs addressing. Whether, it is through increasing the health insurance cover or more effective payment architectures through Government schemes, the need to rein in healthcare costs is paramount for any patient.

Health Education & Access to Information

Doctors often rue the increasingly witnessed trend of patients using the Internet to arrive at conclusions for their medical condition and treatment. When questioned, patients often cite the lack of information being made available to them by doctors or the health system as a whole. The reliance on the Internet maybe driven by the ease of access to information online, the reliability of information and its applicability in progress of any disease is questionable. The health system must help in creating wider awareness on the entire spectrum of health subjects including prevention, maternal and child care, management of Non-Communicable Diseases and common myths and misnomers. The advent of social media and increasing penetration of the Internet through mobile phones presents a unique opportunity to “social”ize health information.

As citizens demand more from their health system and hold us responsible for the services offered, the opportunity to innovate and help deliver on the hopes and expectations of all Indians is both onerous and exciting. For policymakers and the health sector, creating a modern health system cannot be achieved without listening to the voices of those for whom it is being created. The more we listen, the better system we will create for the world to emulate.

Ethiopian Healthcare - Sure & Steady

As our plane touches down in Addis Ababa, the capital of Ethiopia, we are pleasantly surprised by how cool the air is and how crisp the sun is. The weather was more mid-summer English midlands than sub-Saharan Africa. More pleasant surprises were in store as we went about our journey to better understand this fast changing country in the eastern part of Africa. Ethiopia is on the rise. There is a visible boom in the country’s infrastructure and the city is dotted with construction sites and real estate development that indicates better days ahead. The Chinese are here busily building away, as is a large expats community as part of the multi-lateral agencies that setup offices in Addis.

As we drive through the city, our taxi driver proudly shows us the city center with its new shopping malls, hotels, business centers and the new African Union building. The aspiration is clearly to become the Geneva or Vienna of Africa, the veritable capital of Africa. We were keen to understand how this country transformed from the gloomy days of the 80’s and 90’s when a military Junta ran the country to a more reformist, democratic yet very tightly controlled country now looking aspiringly towards the future.

Ethiopian healthcare, like much of the country, is also undergoing a sea change. A raft of reforms - introducing a professionalized cadre to manage public hospitals, restructuring of the payment and payer architecture, federalization of governance and introduction of quality monitoring in public health have created a better, more well managed system. The pubic health system is not without its shortcomings. Much like India, there is overcrowding and often inefficiencies that riddle the delivery mechanism. Availability of infrastructure – medical and non-medical and the crippling power crisis is a bane to the delivery of quality care. When we visit the Black Lion Hospital, the largest public hospital in Addis and a part of the University of Addis Ababa Medical Centre, long waiting lines await us. The availability of diagnostics and investigative infrastructure is often patchy as are long waiting times. Having said that, the center is free at the point of use and offers primary, secondary and tertiary care. The new Cardiac Centre is state of the art and well equipped, however, the availability of trained manpower remains a critical issue in its optimal use.

The inadequacy of the public system has led to a growth in private healthcare. As I sit down with Prof. Kabede Oli, CEO of the rather aptly named Landmark Hospital, I ask him about how private healthcare has evolved in the country. “There is unprecedented growth in private provisioning, given the gaps in the system and a more demanding patient base”, says Prof. Oli, over a cup of aromatic Ethiopian coffee that is peaty and sweet all at once. Prof. Oli has straddled both sides of the system. Having spent his career in the public system, he points to the merit and demerits of both the public and private system. The drivers for private healthcare remain much like anywhere else in the world. A rising middle-class not averse to spending money for quality. Some good practitioners moving from the public sector to setup independent practices. The pressures on the public health system. A growing penchant for an open economy that will surely further accelerate this growth.

I ask Prof. Oli about a possible divide between the private and public health systems. Between the haves and have-nots. His answer was indicative. He says the divide is growing, especially since there has been an exponential growth in private healthcare. Though he still argues that private healthcare will help the system by reducing the burden of the public sector. There is no doubt that the health infrastructure in the public sector is in need of the type of investment that one sees in the private sector.

What is heartening to note is the aspirations that have swept the country and its people. Dr. Oli asks me about the requirements of Joint Commission International, an international accreditation agency known for its stringent quality standards and demanding assessments. As aspirations and incomes grow people will come to expect quality, and with that one hopes more hospitals aspiring for outcomes and not just outputs.

The growing burden of Non-Communicable Diseases (NCD’s) in Ethiopia is very evident. Most specialists I spoke with noted an increased rate of diabetes, heart disease, cancer and infectious diseases. This has led to new innovative delivery models now being established. Dr. Gavit, a practitioner who has worked in diverse health systems like those of the United States, the United Kingdom and Germany proudly showed me his new medical center. He intends to use the facility primarily for preventive health checks and disease management. He says there is a growing need for such infrastructure given the changing demographics and disease profiles.

I ask Dr. Gavit about what he believes would be the future of Ethiopian healthcare. Like many others he expressed his country’s desire to create a health system that is self reliant, efficient and self-sufficient. Most health practitioners here hold India as a shining example of healthcare that is advanced, yet accessible. Where public and private healthcare need not have an antagonistic existence.

As I was boarding the plane back to India, I noticed a mother carrying her child, clearly in need of advanced neurological attention. She told me that she is going to a hospital in Delhi to seek treatment. I asked her why did she not use the hospitals in Ethiopia. She replied plainly, our system is good for basic care and some advanced care, but for specialized treatment, we have to look for options abroad. As I wished her luck, it helped me contextualize the changing healthcare landscape of this vast and beautiful country, which has an ancient culture, language and history. It lies at the cusp of moving from a externally reliant system to a more self-sufficient one, aspiring to ensure that its system can take care of its citizens. It could well look at India to learn on the opportunities and pitfalls that our system has to offer its citizens as its looks to dominate the African social, political and economic discourse.