Bypass for the health sector

Anyone who’s met Dr Devi Prasad Shetty, if only at a public lecture, as I have, cannot but be impressed by what he’s achieved. It’s not just that he’s the first cardiac surgeon to conduct a neo-natal open-heart surgery in the country or that the Narayana Hrudayalaya he set up in Bangalore in 2001 with a generous donation from his father-in-law has completed over 11,000 open heart surgeries, of which half were on children (if you include the Rabindranath Tagore Institute of Cardiac Sciences in Kolkata, the number of open heart surgeries goes up to around 20,000). What’s striking is the manner in which Shetty is transforming the country’s healthcare system and the self-imposed factors, which, he says, are keeping back the country’s healthcare system.

Shetty’s method to ensure the poor get access to top-class heart care, to begin with, is to use the money paid by full-fee patients to subsidise those who can’t afford it—Hrudayalaya’s ratio of non-poor to poor patients is 60:40. While that’s heart-warming, it’s hardly revolutionary, and certainly not scalable. Like the Aravind Netralaya that management guru CK Prahalad never tires of citing, Shetty’s approach to lower healthcare costs has also involved scale—Shetty describes it as the Wal-Martisation of healthcare.

According to a case study done by Harvard Business School (HBS) on the Hrudayalaya, Dr Shetty’s team performs approximately 19 open-heart surgeries and 25 catheterisation procedures a day, a figure that’s around eight times the average for Indian hospitals. Similarly, while other hospitals run about two blood tests on a machine, Hrudayalaya runs 500 a day. It doesn’t buy expensive cardiac care machines, but pays suppliers a monthly rental for parking their machines there and for the reagents they buy to run the machines—Shetty told HBS that, since their demand for reagents was so high, suppliers found the arrangement profitable. The two hospitals, in Kolkata and Bangalore (and two smaller units), combined their purchase orders to get a 30-35 per cent discount on supplies. The list goes on. As a result of this, an open-heart surgery costs around Rs 1.1 lakh here, as compared to Rs 2.5 lakh at an average Indian hospital.

In order to provide cardiac care for the rural poor, Shetty tied up with the Indian Space Research Organisation (Isro) and established a telemedicine project connecting nine coronary care units (CCUs) across the country with the Hrudayalaya and the Tagore Institute and trained ordinary GPs and technicians to operate the equipment and perform essential tests—a software firm was roped in to allow the ECG to be transmitted over a web connection, and digital X-rays helped cut costs dramatically. Between 2001 and July 2004, Hrudalaya’s doctors performed 9,591 telemedicine consultations and the nine coronary care units linked to it treated 4,077 in-patients. According to Shetty’s interview with HBS, once thousands of CCUs are networked, telemedicine can be self-sustaining for just a few rupees a patient.

Apart from the telemedicine, which has great potential applicability for other non-coronary healthcare, Shetty’s other major initiative is the Yeshasvini medical insurance model, which, in a country that has less than a million medical insurance policies, will cover 13 million farmers this year. The scheme gets each farmer to pay Rs 10 a month (the government contributes Rs 5), and, unlike any other insurance scheme in the country, does not have any exceptions for pre-existing ailments. Shetty roped in 150 hospitals, where Yeshasvini card holders can get free treatment (the scheme covers 1,700 types of operations). Till date, the self-funded scheme has done over 100,000 consultations, 35,000 surgeries, and 2,500 heart surgeries.

Even more startling were other revelations made by Dr Shetty during a talk organised by Delhi-based National Institute of Public Finance and Policy, as part of a project it is doing with the US Agency for International Development. Indians, it appears, are very prone to heart problems, and the country needs to be conducting around 2.5 million heart surgeries a year. But, thanks to the paucity of facilities, only around 65,000 get done each year. This paucity of facilities refers not just to hospitals (while doing the Yeshasvini research, it was found that just 35 per cent of the hospital beds in Karnataka were being utilised), but to other important areas like doctors, nurses, and technicians.

For a population less than a fourth of ours, the US trains 800 cardiologists, as compared to India’s 80. Shetty says he tried to get the medical authorities to increase the number of seats for over four years, but failed. Finally, he tied up with Indira Gandhi National Open University (Ignou) to offer a post-graduate diploma in community cardiology—Ignou can offer this degree without requiring the medical authorities to approve it. Similarly, Shetty confessed to fighting a losing battle to get the authorities to sanction more seats for training nurses, who are in tremendous short supply, both locally and globally. Did you know the National Health Service of the UK is the third-largest employer in the world? There is, believe it or not, even a huge shortage of technicians who can operate certain coronary care equipment but there is no recognised programme to offer such training in the country.

What’s required are solutions that make the best use of resources. In the US, for instance, Shetty says, trained technicians operate dialysis machines but since this is not allowed in India, the treatment becomes expensive. Indeed, in the early ’90s, the medical profession convinced the courts to rule in favour of banning ayurvedic and homoeopathic doctors from referring to themselves as doctors—since no MBBS doctors want to spend their lives in villages, this effectively ensures limited health facilities for rural India. The saving grace is that, once Shetty’s talk was over, an official from the Prime Minister’s Office walked up to him, requesting him to join some panel being set up. Hopefully something will emerge from this.