Health: Band-aids will not heal a system that needs deep attention

In our country, over the past few decades, we have equated medicalized healthcare with health.
In our country, over the past few decades, we have equated medicalized healthcare with health.


  • We need the sector’s basics addressed for substantive progress to be made. Nutrition, primary healthcare and preventive and community health should be focus areas too.

During the first eight years of my professional career, I worked in the health sector. My role entailed helping finance healthcare providers, mostly through loans. From tiny clinics in small towns to the largest hospital chains in the country. What I learnt during those days has been the foundation of my career.

What made that role unusual was that people seeking our financing would eagerly share their methods of making money, including their darkest secrets. They wanted to prove that our money was safe with them and that we would get good returns. Unethical practices were the main financial driver for far too many. Unnecessary diagnostic tests and treatments, including drugs and hospitalization, along with overpricing, was standard. This was rampant abuse of power over patients and families dependent on them for relief and often their lives. These unethical practices ranged from the criminally brazen to the subtle, things that could be passed off as ‘professional judgement.’

While I did come across ethical and competent people and hospitals, they were a smaller proportion, perhaps about 20%, while the rest were on the spectrum from brazen to subtle malpractice.

Its only later that I read Kenneth Arrow’s seminal paper, ‘Uncertainty and the Welfare Economics of Medical Care.’ Arrow’s framework abstracted what I experienced every day. Some of these aspects were: When healthcare services are required is uncertain; i.e., you don’t know when and what illness will strike. It is unclear that a given diagnostic test and/or therapy will lead to a sustained positive outcome, or cure. You can’t shop around and switch doctors like soap. And doctors have enormously more knowledge than patients, so it is a relationship with a grossly asymmetric distribution of power. This let corruption and malpractice grow.

Four years ago, we began expanding our Foundation’s work into health, and then covid tore up our step-by-step plans, throwing us into the deep end. Two decades after my initial stint in this sector, I was back, and the detrimental effects of the weak foundations of our healthcare system could not have been more apparent. For all the transformations India has witnessed over the past two decades, its basics were unchanged.

First, a fundamentally flawed assumption that lies at the core of our approach. Clinical interventions and medicines to cure ailments are not the same as a system that fosters healthy individuals and communities. Medical services can only be a subset of a robust health system. In our country, over the past few decades, we have equated medicalized healthcare with health. This overmedicalization of health has economic and well-being consequences for our entire society.

Second is the direct implication of overmedicalization: woefully inadequate attention to and investment in nutrition, preventive and community health, and primary healthcare, while great pride is taken in a few large tertiary care hospitals. This structure essentially means that the system does not do much to keep people healthy. Then when they get ill, the system does not take care of them quickly or early enough. And when things become really bad, some of these people find their way into big hospitals. Most aren’t as fortunate. Such a system is structurally costly and ineffective in both economic and human terms.

Third, we have failed to develop front-line human capacity, ranging from community health workers to doctors, and empower it. Many issues plague this most important of matters. There is little importance given to the critical role of front-line workers and their working conditions. There are limitations of quality and capacity in the education system that prepares them. And they play their roles in difficult conditions, with a paucity of resources, given the system’s weak support and culture of indifference. Then there are dysfunctional and unreal professional licensing norms that stunt the real scope of roles. For instance, even a pill of paracetamol can only be prescribed by MBBS doctors.

Fourth is the heavy overdependence on private healthcare providers. Not just the large gleaming tertiary hospitals, but the small ramshackle ones, as also the seedy clinics in by-lanes and quacks who go by many names. This phenomenon is also fed by chronic under-investment in the health sector and the inadequacy of our public health system in the country, with a few states as notable exceptions.

Fifth, the outcome of weak public services and over-dependence on the private sector is egregiously unequal access to healthcare across economic classes and geographies; for example, rural versus urban and eastern versus southern states.

Sixth, with the absence of quality healthcare facilities, health insurance doesn’t solve the problems of healthcare, let alone of health. If you don’t have a hospital or doctor to go to nearby, how can insurance help? And when the methods of a large proportion of private players are well known, which insurance system will trust their claims, unless there is collusion?

Seventh is the widespread rot of professional corruption that I described.

Without doubt, many things have been done to help improve the health system in India in the past few years. But we need to transform these basics to ensure good health for all our people. Which, along with good education and high-quality jobs, form the foundation of societal well-being.

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