A Time to Let Go

Aruna Shanbaug, who worked as a nurse in a Mumbai hospital was raped and strangulated by a fellow hospital employee in Nov 1973. It has been more than 37 years that she has been living in a vegetative state in a Mumbai hospital. She is forced fed by her care providers. She can not express herself and her medical team believes that she has no chance of any medical improvement. Pinki Virani a Mumbai based journalist and author, who has written a book on Aruna has now moved the Supreme Court of India, requesting that she be allowed to die peacefully.

Euthanasia or mercy killing is illegal in India. The courts have acknowledged the complexity of the issue many a times earlier as well. While the courts may debate the pros and cons of legalizing mercy killings, many people in the medical world believe that allowing terminally ill people to die peacefully is as much a part of good medicine as it is to fight disease. A good doctor knows when it is time to give up and accept defeat against a disease and let the patient go. Prolonging a patient’s agony by keeping him alive in a vegetative state, using machines, which replace human organs is very wrong.

Thus, the critical issue here is when does one decide that time has run out for a patient and accept that nothing more can be done. Can a doctor say with utmost certainty that there is nothing that medical science can do to pull a patient back from the brink? When do we pull the plug and feel no guilt about letting a dear one go? This is where most doctors hesitate, hold on for a little longer, clutch at straws such as minor improvements and hope against hope that a miracle may happen. Doctors too are humans, they are trained to fight to save life and not take it, and they are very uncomfortable in pulling the plug even when they can read the writing on the wall.

I remember the time last year when my grand mother all of 105 years lay critically ill in a hospital in Delhi. She was admitted to the hospital with a gastrointestinal infection, which had seriously dehydrated her. As a consequence of this her electrolyte balance had gone askew and this had impacted her kidneys, which had shut down. The doctors treating her were former colleagues and friends. They tried their level best to save her, managed to get her infection under control with antibiotics, managed to get her electrolytes balance back to normal and put her through many dialysis hoping that her kidneys will restart. We watched helplessly as our grandmother put up a brave fight. She virtually disappeared under the tubes, which seemed to be sticking out from everywhere. We reached a stage, where she and we knew that the end was near. Yet we wanted a miracle to happen, we kept telling the doctors to keep trying and not give up. None of us including our doctors wanted to take the decision, which was but inevitable. Eventually we did realize the futility of our efforts, we asked the doctors to allow us to take her home, where two days later she passed away peacefully.

Now is this euthanasia? Isn’t it how all of us would want to bow out from the world with dignity, in our own beds surrounded by people we love. Won’t we want our doctors to be wise and courageous enough to accept defeat and let us go, rather than needlessly keep fighting against the inevitable. I believe that the canons of medicine do allow doctors to stop treating, when nothing more can be done. Moreover, I would like to believe that the doctors must also help by making once passage as painless as possible and all this should happen with the patient’s or their immediate family’s active and informed consent.

Why shouldn’t we trust our doctors in death as much as we trust them in life? The law must allow doctors to take this final call keeping the best interest of the patient in mind. The law must define a reasonable protocol to be followed for passive and active euthanasia and let the medical folks do their duty as best as they can.

Marketing A Laparoscopic Surgery Program

Marketing a surgery program is fraught with risks. Barring surgeons, I am yet to meet someone who looks forward to a surgery. Most people try to avoid surgery as much as they can. They will come up with all kinds of excuses including astrological considerations, the weather not being right (it is either too hot or cold or raining) or waiting for a son or a daughter who lives abroad to arrive before they can go under the knife.

The fear of surgery is universal and whatever the surgeon might say (I have done it a thousand times, I do it every day etc.), the fear of surgery just does not dissipate. Whatever the surgeon may say, the fact remains that patients undergo surgery only when they do not have any other medical recourse. Given a choice between a surgery and any other non-invasive medical procedure a patient will always choose the latter.

Now, marketing a surgical program, which no one wants (or at best agrees to only as a last resort) is to say the least, challenging. With the advancement of technology a whole lot of surgeries can be done using a laparoscopic techniques. This is indeed a great boon for patients, who as I mentioned earlier are extremely reluctant to go under the knife and by corollary once subjected to surgery are very keen to return home to normal life. Laparoscopic surgery, which is also at times called Minimally Invasive Surgery allows surgeons to operate with just a few holes through, which they insert a camera and other equipment necessary for the surgery. Minimally Invasive Surgery is far superior to conventional open surgery as it is a lot safer, allows faster recovery, has less chances of infection and usually involves minimal loss of blood.

To effectively market a laparoscopic surgical program it is essential that the patient understands its huge benefits. Since, patients after a surgery want to return home faster, I would suggest that we brand the laparoscopic surgery program as ‘Short Stay Surgery’ program. This is easily understood by all and has a certain appeal for patients-instead of focusing on surgery, they would rather look forward to a short hospital stay and a quick return to home. Fortunately, many surgical procedures done laparoscopically allows patients to return home with in 24 hours, which is just great.

Once the program is branded as ‘Short Stay Surgery’ program the other benefits of the program must be highlighted all flowing into the core benefit of a short stay in the hospital. The surgeons in their spiel should highlight this aspect of surgery as much as they can. This is not to say that they should gloss over the risk factors of the surgical procedure, it is just that the prospect of a possible shorter stay in the hospital will make the patient feel a lot better.

The advertising communication should highlight facts such as faster recovery, minimal scarring, less pain, low blood loss and less chances of infection as clear advantages of laparoscopic surgery. It should then connect this up with the core benefit of a shorter stay in the hospital. I believe such an approach can go a long way in popularising minimally invasive surgery and patients will actively seek a surgical intervention at the right time rather than wait till there is an emergency and waiting may no longer be possible.

The tonality of messaging is just as critical as the message itself. One has to be very careful in not sounding over enthusiastic and too keen in the advertising. One must remember that inspite of all the advantages of laparoscopic surgery, it still is surgery. From a patient’s perspective this involves a detour to the hospital and the attendant risks can not be just wished away. The communication must be couched in a language, which is solicitous, understanding and educative. It should connect with the patient and help him understand that the short stay surgery program lessens risks significantly and allows him to get over the medical crisis faster.

The use of media of course depends on the budget available with the hospital. Print, Television, Outdoors, Radio, digital and BTL can all be effectively used to create an impactful campaign. The choice of media can amplify the messaging and help more people connect with the hospital.

And choose laparoscopic surgery in time rather than wait till they are left with no choice.

Thoughts on Cadaver Organ Donations in India

Organ donation in India is still in its infancy. Everyone from the Union Health Minister Ghulam Nabi Azad to doctors working in both private and public sector hospitals concur on the need for more donations and advocate the creation of Organ Banks, greater public awareness about the noble cause of organ donations as well as on the urgent need of passing laws and developing transparent, hassle-free mechanisms, which allow swift organ retrieval, banking and transplantation.

I believe that the entire Transplant Program suffers from at least three severe malaise. These are lack of governmental regulation, poor infrastructure for quick retrieval and transplantation and total public apathy.

Apparently a comprehensive ’Transplantation of Human Organs Act’ is being considered by the Indian Parliament. The act once cleared by the parliament will hopefully lead to a far better utilization of the donated organs and create a network of Organ Banks, which would be able to freely exchange information about the availability of an organ, its swift retrieval, its likely recipient and the hospital, where the procedure might be done. While one can hardly fault the government on its intent, the execution of the program will determine its success.

The government must establish clear guidelines on brain death, when can organs be harvested, which hospitals (both privately owned as well government hospitals) are notified for organ harvesting as well as transplants, who all can donate an organ and what would be the process for locating the recipient once brain death has been established.

I would recommend that the government should establish an autonomous body, comprising of eminent doctors, organ transplant surgeons, lawyers of repute and other medical professionals who can come together to formulate guidelines on organ donations and transplants, establish mechanisms for quick retrieval and harvesting of organs from a brain dead donor and most importantly locate a recipient awaiting a transplant.

A national registry of all those who are in need of organ transplant should be established forthwith. It should list all individuals who need a transplant and should have their detailed medical records available on the touch of a button. The registry should also list organ banks and the hospitals who have the infrastructure and the capability to carry out transplants. These hospitals must have nodal officers/doctors, who can act quickly once a brain death has been established. These officials should access the medical records of those listed as needing an organ on the national registry, check out if they are suitable candidates for receiving an organ, establish the logistics of getting the organ and the recipient together at a hospital where a transplant can be carried out and than start the process of getting the patient and the organ to the hospital.

While, this may sound simplistic, this would require immense coordination and effort. This calls for a dedicated body, state of the art IT infrastructure, logistical support in safely transporting the organ, getting the recipient to the hospital at a moment’s notice and gearing up the hospital for a fairly complicated surgery at a very short notice. The government must take the lead in setting up this mechanism and ensure that it is fast, efficient and incorruptible. Most importantly the workings of this body, should be completely transparent. I fully understand that often this body will have to take decisions regarding who gets an organ and perhaps a new lease of life and who doesn’t. These will always be hard decisions, involving questions of life and death and must be taken with utmost care, without any prejudice and in a completely transparent manner. Thus, we must have people with a track record of great efficiency and of unimpeachable integrity running this institution.

Last but not the least, it is imperative that the government create awareness about organ donations. Cadaver donations in our country are minuscule. The trauma of the untimely and unexpected death of a loved one itself usually numbs the minds of those, who have take decisions related to donations. To make matters worse, many people still believe in reincarnations and can never imagine donating organs lest it impacts life in the other realm. The government must fight these obstacles resolutely, it should educate people about the benefits of organ donations and maybe reward folks who decide in favour of donations.

Donating organs of a loved one so that people, mostly strangers, get a new life is undoubtedly the most noble of gestures. It requires courage, conviction and immense generosity. The government must ensure that once someone takes a decision like this, the organ reaches the right recipients and many lives are saved. This should happen all the time, seamlessly and without fail.

The Healthcare Marketer’s Life

Yesterday evening while I was returning from work a friend called. He has recently taken over as the Head of Marketing Communications at an upcoming hospital. I had met him a few weeks ago to congratulate him on his new assignment and he seemed quite kicked about his new role. He had grand plans of changing the way the hospital communicated with its patients and other stakeholders, he wanted to run customer facing programs, drive relationships with patients through effective engagement and deliver uniformly great experiences to those who touched the hospital.

Yesterday over the phone Ajay felt he had made a big mistake by joining the hospital. I was quite flummoxed by this turn-around. Further inquiries revealed a familiar story. The hospital has a brand new CEO, someone who has worked for many years in hospital operations but have no knowledge or appreciation of communication. However, like most folks he too believes that marketing communications is hardly something to be left to experts. In fact the CEO believes that he knows exactly how a piece of advertising or a brochure should look like. Download the text from the web, adapt it by rewriting some of it, slap a few images downloaded from the net and include the mandatory images of some if the hospital doctors, run it past a few senior hospital bigwigs and, voila the ad or the brochure is ready. As far as hospital signage are concerned, the CEO feels that they really are meant to provide legible directions to the patients and fussing over them, their aesthetics and design is a gross waste of time, energy and money. Well I might be exaggerating a little here but this is really the long and short of what Ajay felt his CEO was doing and no wonder he had started feeling frustrated in the set up.

Marketing folks in hospitals always grapple with the problem of every one who is anyone coming up and advising them on how to create a piece of communication. Some doctors love to see their pictures in the ads and some other feel great if gory images of them operating heroically could be included in the communication. The CEO’s love to mutilate the advertising copy, insist on correcting perfectly well written text, increasing or decreasing the font and of course having the logo bigger, bolder and always 2mm to the right! Many a times the marketing communication executive has to sweat many hours trying to accommodate the conflicting wishes of the CEO, the star surgeon and his favourite flunky. All in a day’s work for the intrepid marketing guy, who can be forgiven for wondering if he is the only one who knows nothing about marketing communications.

Those who have worked in hospitals long enough know how to maintain a fine balance. They will wait till the last-minute, before asking a doctor to go through the text and approve the ad, they will sneak it past a doctor who they know is not too interested in the brochure’s finer details, they will get the mailer made and when a livid doctor would approach them on their failure to show it to him, they will deftly show an e-mail sent a few days ago knowing fully well that the doctor rarely checked the mail. Tricks of the trade, which one learns on the job.

Well, while all this may sound hilarious, the fact is that a hospital marketer’s life is not easy. If the hospital is doing well, his budgets are the first to be cut (why do we need to spend money on advertising, we have hardly a bed to spare!) and God forbid, if the hospital is not doing too well, the marketer knows that the hospital can hardly spare cash to blow its own trumpet. The doctors and particularly who head various departments are always after his life to see their ads in the newspapers, whether the marketer has the budget for such advertising is of course none of their concern. The CEO is always looking to pinch a few more pennies from a meager budget and he insists on stretching the money to impossible levels.

Such is than the life of a healthcare marketer.

Usually, in all this the silver lining is a boss, who understands the inner dynamics of the hospital, who knows how to work with medical folks without unnecessary confrontations, who lets the marketing guy go about his job without much hindrance and steps in to resolve conflict as it arises. He is the one who understands the aspirations of a good marketer as well as the concerns of the medical folks in the hospital and strives to achieve a balance.

At the end of the day, and in like most other things in life, a fine balance is the key.

The Perils of Standardized Health Care

Can healthcare delivery be standardised? This is the question, which has been bothering me this week.

The thought itself was triggered by a report in ‘Mint’ earlier this week titled ‘Government plans common healthcare standards’. (http://www.livemint.com/2010/08/24233218/Govt-plans-common-healthcare-s.html)

While the report portrays the benefits of standardization of care with millions of patients receiving standard care prescribed by the government thus saving them from being shortchanged by unscrupulous doctors and mercenary hospitals, there is also a flip (and a more real) side of the argument that we must understand.

While the government pushes through the Healthcare Standardization agenda, one wonders how can the delivery of healthcare be standardized across all medical facilities in the country? Every individual is different, reacts differently to treatments, the doctors are required to take decisions based on their experience and training and not on the basis of a set of guidelines decided upon by the government. If I was to fall sick, I would want my doctor to treat me based on his knowledge and experience and do what he feels is the best for me rather than stick to a standard set of guidelines mandated by the government. All doctors and medical establishment should have one guiding principle – the interest of the patient must be supreme and if there is a situation of uncertainty, I would want my doctor/hospital to always err on the side of caution.

Also, the healthcare delivery model in the country is hugely diversified. In its current form with poor regulation and monitoring it just does not lend itself to any standardization of care.The government-run tertiary care hospitals in large cities are filthy and over-crowded with patients and over-worked and under-paid doctors. The government run district hospitals as well as Primary Health Centres are even worse off with out dated equipment, poorly trained doctors, who often do not even show up for work. The private healthcare is dominated by secondary care establishments (usually called nursing homes), which have 10-50 beds and are usually owned by a doctor or a group of doctors. These are mostly mom and pop establishments, where owner doctors reign supreme and are answerable to none. Quality of care in these establishment is of dubious standard and these are neither properly regulated nor monitored vis-a-vis outcomes or treatment protocols. Christian missionaries and other charitable institution also run a large number of hospitals and now we have a nascent category of corporate style hospitals coming up in large cities offering cutting edge care. My point-all these hospitals are differently equipped, have differing goals (for profit, non-profit, govt. owned etc.), have vastly different resources at their disposal, have different cultures and widely varying medical expertise available to each of them. How on earth can they all provide standardised, similar quality care to their patients?

Last December my father underwent a prostate surgery in a hospital in Delhi. Elderly men usually require this surgery at some point in time in their lives. Now, while I researched the treatment options for him and took surgeon’s opinions I discovered that we had several options. Our surgeon felt that the best and the safest alternative for him would be a laser surgery involving a cutting edge holmium laser. Now, this option is not available at most of the hospitals even in a city like Delhi, thus it can safely be ruled out from the ‘standardised treatment guidelines’ that are being framed by the government. In a situation like this, will it mean that patients like my father will be denied this option and he will have to endure the conventional surgery with its attendant risks of infection, excessive bleeding and a much longer hospital stay?

Let us now also look at the genesis of all this.

The health insurance companies (mostly state-owned) want treatment protocols for some common diseases to be standardised so that they can fix a rate for these procedures, irrespective of the hospital and the doctor one chooses to go to. For the insurance companies this will lead to a state of nirvana, as they would be required to pay a fixed lump sum to the hospitals irrespective of the bill a patient runs up. They can then squeeze the hospitals further and make greater profits. Now, I am not against profits, however the problems that I see in this arrangement is that the patient will suffer, the quality of care will go down as hospitals will try to manage the delivery of care with in the financial limits set by the insurance companies (after-all they also need to be profitable). This is clearly hazardous.

One buys a health insurance cover to ensure that in the time of need, financial constraints do not come in the way of accessing the optimum quality healthcare. The operative words here are ‘optimum quality’ and not ‘standard quality’ as mandated by the government. To equate these two will be a great folly. If the insurance companies believe certain hospitals are taking advantage of the situation by excessive billing (which I submit happens), they must put in place strict monitoring mechanisms including peer group reviews of treatment provided by the hospital. A healthcare regulator needs to be set up by the government to arbitrate between insurance companies and the hospitals. The regulator can possibly frame broad treatment guidelines, which can serve as references in case a dispute arises between a patient, the hospital and the insurer.

Standardizing treatment protocols in a healthcare environment as complicated and as unregulated as ours is a dangerous and mostly an impractical idea. We need to first standardize our healthcare delivery systems before even thinking about standardizing treatment protocols. Paying hospitals based on these standardized treatment protocols because it makes health insurance companies profitable is inviting hospitals to cut corners. Once this happens, it will lead to serious erosion in the quality of care and even more importantly a big trust deficit between patients and hospitals will emerge.

That would really be the ultimate irony, for if a patient does not trust his doctor or hospital, he really would have nowhere to go.

The Fight Against Malaria

Earlier this week I was in Mumbai. Monsoons in Mumbai usually mean unrelenting rain, it drizzles and then suddenly it pours and is again back to the drizzle, it never appears to stop raining. Weatherman have been unanimous in asserting that this year so far has been one of the wettest in Mumbai in the last 5 years. While the rains have been bountiful, Mumbai has been shivering like never before-it is in the grip of an epidemic of malaria.

The evening broadcast on the television confirmed a few deaths and put the numbers affected by the disease to a few thousands, with over 800 fresh cases reported in the last few days itself. The hospitals are overflowing with the sick. In fact such is the press of patients that Mumbai Hospitals are setting up huge tents on their premises and putting additional beds to cope with the patients. Raj Thackeray the looniest Shiv Sainik has already blamed the North Indians living in Mumbai for the disease. Incredibly he believes that these people living in squalor in Mumbai are spreading the disease and the outbreak will stop if Mumbai was rid of this scourge.

Unknown to Mr. Thackeray, malaria parasite has a history, which dates back to over half a billion years. The origin of Malaria can be traced to Western and Central Africa. About half a billion years ago the pre parasitic ancestors of the malaria parasite adapted to live in the gut of a some aquatic animals. They subsequently proliferated and evolved to live in insect larvae found in still water bodies. These insects first appeared around 150 million to 200 million years ago. During this period, certain lines of the ancestral malaria parasites achieved two-host life cycles which were adapted to the blood-feeding habits of the insect hosts. In the 150 million years since than, many different lines of malaria and malaria-like parasites evolved and radiated. The malaria parasites of humans evolved on this line with alternate cycles between human and the blood-feeding femaleAnopheles mosquito hosts.

With the advent of agriculture and human settlements, the density of the human population increased. These settlements largely concentrated along inland water bodies. Thus the mosquito population thrived feeding itself on a large and stable supply of human blood. From its origins in Africa Malaria spread rapidly across the globe and became the worst killer disease known to humans. The Chinese knew about Malaria 5000 years ago and Egyptian mummies with enlarged spleens are believed to be the remains of ancient Egyptians who died of Malaria. The disease was rampant in the Indian sub-continent 3000 years ago, Alexander the Great is believed to have died of Malaria in 323 BC, on his way to India. The disease reached the Mediterranean about 2000 years ago and invaded Europe almost a 1000 years ago. Increasing trade and military conquests spread the disease globally and by the 18th century the scourge was at its peak with half the world’s population at risk. Poor living conditions, famine and poverty contributed to high mortality.

As the western world advanced, living conditions improved contact with the vector declined leading to a spontaneous reduction in Malaria in those parts of the world. By the middle of the 20th century Malaria had been conquered in North America and Europe. However, the fight for eradicating Malaria continues in the tropics.

As the fight against malaria accelerates the world over, an estimated USD 10 bn are being spent in an effort to eradicate it. The goal of this world wide effort is stop all malaria deaths by 2015 and finish the disease by 2035. The fight is a global effort to improve the living conditions of people in the third world, provide effective protection (such as chemically treated mosquito nets and new generation mosquito repellents) and provide easy access to medical care even in the worst affected and remotest parts of Africa. Global pharmaceutical companies are researching the disease like never before in the hope of finding more effective drugs that can significantly bring down mortality.

Going by what I saw in Mumbai, I shudder to think how ordinary people must be coping with this outbreak in the rural areas, where healthcare services are almost non-existent. The time has now come to take up the fight against Malaria pretty much like the government has been fighting tuberculosis and polio in the country. The government’s flagship health scheme the National Rural Health Mission, must take the lead and orchestrate a nation wide initiative against malaria. A sustained effort should be made in educating people about the perils of Malaria. The government should take preventive steps such as defogging of the vector’s breeding grounds the distribution of medically treated mosquito nets and free distribution of mosquito repellents may help prevent the disease. The Primary Health Care centres must be equipped with kits needed to quickly diagnose and treat the disease. The government health workers should be able to proactively report the likely cases and the PHC doctors should be able to intervene to stymie the disease before it becomes fatal.

All this and more is possible only if there is a will. The money can be found. More than anything else we need dedicated people who feel strongly about this ancient scourge and who are willing to lead in this final battle.

Health Insurers Vs. Hospitals-Patients Pay

So the health insurance companies have started tightening the screws on private hospitals in India. The tussle between health care services providers and the health insurance companies have been on the cards for a while now. The sordid affair burst into the limelight last week, when India’s 4 largest general insurance companies, all owned by the government of India, refused cashless services to patients in these hospitals. The insurance companies can easily do this, by throwing out these hospitals from the network of hospitals, whose patients are entitled to this benefit. The fine print that you and I sign, while buying an insurance policy says that we are entitled to cashless services in select hospitals only and the insurance companies can change this network at their sweet will.

Well, for the uninitiated here is what the problem is. Health Insurance companies believe that hospitals overcharge patients who have an insurance cover simply because the money is to come from the insurance companies. Insurance companies for long have been asking hospitals to agree to fixed rates for some common procedures and surgeries. The hospitals have been resisting this as they believe that these rates are too low and in medicine, it is quite impossible to have fixed packages for surgical procedures etc. Large private sector hospitals, who offer high standards of medical care and pride themselves on their state of the art equipment, doctors, nurses etc. believe that at the rates offered by these PSU insurers, they will not be able to maintain their standards and lose money. Thus the impasse.

Now, here is the truth. The insurance companies by and large are right in accusing the private hospitals of overcharging patients who have an insurance cover. However, in many hospitals this is not deliberate. It is just that if a doctor is in doubt about ordering a test, he invariably would ask for the test, if the payor is not the patient but is an insurance company. This is largely because he wants to be sure of his diagnosis and reduce the risk of his clinical judgement being wrong. Now one may argue that the additional test, constitutes better healthcare and the doctor is well with in his right to ask for it and viewed from this perspective, this would hardly qualify as ‘overcharging’.

The other reason for inflated bills is that we as consumers do not feel the pinch even if the hospital bill is more than what we had thought it might be at the beginning of the hospitalisation. Since the insurance company is paying we would insist on top of the line stuff for ourselves. It hardly matters, whether we really need it or a cheaper option might have been just as effective, things that we would surely consider if we were paying out of our own pocket. I recall when my father underwent a prostate surgery last year, we ran up a bill of close to Rs. 200000, which I thought was on the higher side. However, since we had insurance, I hardly felt the need to either question the doctor or the hospital. I believe, mostly this apathy of the hospital as well as the consumers towards insurance payouts inflates the bills.

Apart from inflated bills the insurance companies also believe that hospitals defraud them by manipulating patient histories and making claims on behalf of the patients, who would otherwise be ineligible for the claim. This mostly happens if a patient has a pre-existing condition (ordinarily not covered), which the hospital’s doctors would try to hide from the insurance companies. Well, there is a grain of truth in this as doctors occasionally do try to ‘help’ their patients. This is mostly on the request of patients, who desperately want to make a claim even when they know that they are not eligible. The doctors try to oblige their patients either because they have an existing relationship with the patient or when they fear that if they do not ‘help’ the patient he will go to another doctor, who will do the needful. Thus losing a patient for something like this makes little sense to them.

The insurance companies on the other hand are always looking at ways and means of denying hospitals claims, which are perfectly payable. They arbitrarily make deductions citing obscure and often questionable reasons. Many a times they release the hospital’s payments without even informing them that they have deducted part of the money. The payments are rarely made on time, the third-party administers (TPA’s) working for the insurance companies are given targets to reduce payouts to hospitals and the system is hugely inefficient. Hospitals have to incur costs by hiring people, whose only job is to follow-up with the insurance companies and TPA’s about the money owed to them.

A summary cessation of cashless facilities in private sector hospitals is hardly the solution that works. The insurance companies need to work together with the hospitals to sort out their differences on a case to case basis. The hospital as well as the insurance companies must appoint reasonably experienced and mature people to manage these relationships, who should regularly meet and discuss all cases, where the insurance company feels that the hospital has overcharged. These cases should be thoroughly investigated and if a doctor is found complicit, he should be asked to explain. The insurance companies and the hospitals should organise training programs for the doctors, making them aware of how ‘helping’ patients helps no one. If the insurance company finds a hospital’s administration itself involved in shady practices than of course they must throw the hospital out of their network. On pricing, the insurance companies must accept that hospitals have a right to price their services as they deem fit. Most hospitals will price themselves according to the quality of their services, the pull of their brand and the existing market realities. The insurance companies must accept these prices and maybe they can ask for some discounts based on the volume of business they conduct with a particular hospital. Dictating prices to a hospital is bad policy as the hospital when squeezed hard will cut corners thus compromising on patient care.

Finally as consumers, it also devolves on us to be more prudent about our healthcare spends in a hospital. We should be as careful with the insurance money as we would be with our own. If we don’t and the insurance companies keep bleeding we will either end up paying higher premiums or worse, will have no cashless services in spite of having an insurance cover.

The Need for Better Corporate Health

It was 7 PM in the evening in our Mumbai office. The day was winding down and it had been a hectic day for the sales people. The CEO wanted to review the sales plans and he had asked each sales person to present their targets and plans. We have a reconstituted Mumbai sales team and the CEO wanted to use the opportunity to interact with each sales person and also do a first hand assessment of the talent we had on b0ard. He was done with the junior most team members and now he was planning to have one final round of meetings with the supervisors to share his views and provide feedback.

As the meeting with the Managers got underway, one of our most experienced sales person, Alvin started feeling a little uncomfortable. Alvin is 36 years old and is a veteran in the industry. He has been working for us for close to 3 years now. Alvin started sweating profusely, was breathing in great gulps and was clearly distressed. He complained of tightness in the chest, heaviness all over and seemed to be unable to keep his eyes open.

As Alvin collapsed no one seems to know what to do. Someone got him down to a car and they rushed him to the nearest hospital. The Mumbai roads were as usual clogged and it took them at least 45 mins to reach the hospital. During this time, there was no one who could provide first aid and everyone prayed that nothing should happen to Alvin before they reach the hospital.

Scary isn’t it? But this is how most offices in India are. There are hardly any provisions for managing an untoward incident in the office. There are no trained personnel, who can provide basic life support till help arrives and there are no emergency protocols defined or practiced, which may help in managing a medical emergency at the work place.

There is no denying the fact that work place health is amongst the most neglected in most corporates in India. With increasing levels of work stress, sedentary lifestyles late nights and weekend business parties, corporate India today offers a lifestyle, which is fast paced and quite deadly. Coupled with pressures at home with nuclear families and live in helps being the norm, life for most people in big cities is a roller coaster and this is taking a gradual toll on everyone’s health.

Lifestyle diseases including cardiac diseases, diabetes and hypertension are catching their victims young and often by surprise and corporate India is just not equipped to handle this.

It is imperative that corporates start paying serious attention to the health of their employees. Annual health checks must be mandatory and should be taken a lot more seriously than now. It would also help if the companies could hire the services of professional counselors, who can interact with the employees regularly and shepherd them through periods of heightened stress either at work or home. There is no harm or shame in having shrinks at the workplace to help employees cope with a crisis that may be lurking round the corner. An organisation must maintain a health register of all its employees detailing their existing conditions, their risk factors, lifestyle choices, allergies, emergency contacts, family physicians et al. This information should be maintained and updated on an annual basis and should be immediately available if required.

It would also be a good idea to train a few employees in Basic Life Support techniques. I would recommend at least 1 trained person per 50 employees would be a good ratio. Everyone should know that they need to call in case of a medical emergency at the work place. Hospitals in Delhi usually help train employees and they rarely charge a fee. While, I worked in the hospitals, we made a special effort to organise these trainings. Yet, I recall, we struggled to get corporates to allow to conduct these. Most corporates looked upon these as a waste of time and a kind of marketing activity for the hospital happening on their premises.

It would also help if the corporates had a clearly defined emergency protocol and people identified who would coordinate the medical evacuation. In Alvin’s case, we rushed him to the nearest hospital. As luck would have it, this hospital did not have a cardiologist in the emergency, it did not have a cath lab, a 3 D echo any other kind of emergency cardiac support. While, they managed Alvin as best as they could and stabilised him, we were plain lucky that Alvin was not having a heart attack. Investigations later revealed that Alvin suffered from hypertension and had a deranged lipid profile. We also knew he smoked like a chimney, loved alcohol and led a wholly sedentary life. He was under immense work pressure, spent more than 3 hours commuting from Thane everyday and was trying hard to juggle personal and professional life as best as he could.

For him this was a warning sign. His body is protesting against constant neglect and abuse. For the corporate too it is a big red light. We should have known about Alvin’s medical condition in advance. More importantly we should have been better equipped to handle the kind of medical emergency we faced all of a sudden.

This unfortunately is not just our story alone. It is happening all too often in many organisations. We need to sit up, take notice and try to create a healthier and medically better prepared workplaces.

To protect the privacy of the employee, I have changed his name.

The Apollo Clinics-The Perils of Franchising Healthcare Services in India

I came across a piece co-authored by my former colleague Ratan Jalan in ‘Marketing Health Services’ (Eye on The Indian Market, Spring 2009 edition)of the prestigious journal of the American Marketing Association. I have known Mr. Jalan since he hired me to work for him at Apollo Health and Lifestyle Ltd., many years ago and hugely respect his scholarship and knowledge about the business of healthcare in India. However, I must confess that I do not quite agree with Mr. Jalan’s portrayal of the opportunities in franchising healthcare services in India and his conclusions about Apollo Health and Lifestyle’s successful franchising of the Apollo Clinics.

Apollo Hospitals is one of the largest chain of hospitals in India. It has in its network more than 41 hospitals and manages over 8000 beds mostly in the secondary and the tertiary healthcare space. I met Ratan in the year 2001, when he was setting up Apollo Health and Lifestyle, which was to get into franchising of the Ápollo Clinics, the primary healthcare services chain, which were supposed to complement Apollo’s large secondary and tertiary care network. These clinics were envisaged as a franchised operations, supported by the Apollo Hospitals group. They were to leverage Apollo’s excellent brand equity and knowledge about the healthcare in India and help franchisees run a profitable enterprise.

The Apollo Clinics were well conceived. The service mix was essentially OPD consultations, a collection centre for pathology samples, radiology services (X-Ray, Ultrasound) and basic cardiology diagnostics (ECG, TMT and Echo). The clinics also had a 24 hour pharmacy and basic preventive health packages were also offered. We worked hard on the look and feel of the clinic (Ratan had Alfaz Miller design the clinic interiors), Ravi Bajaj was to do the staff uniforms, and the clinics were to hire smart and well-trained youngsters to be the face of the clinics. The consultants were to from the local areas and it was thought that Apollo Hospital’s senior consultants will also run their OPD’s from these clinics.

On the business side of things a franchisee needed to invest close to Rs. 20 MN upfront. The business plan included a fixed percentage payout by the franchisee of the revenue that he made. Apollo was to handhold the franchisee through the setting up of the clinic, purchase of medical equipment, development of the software to run the clinic, recruitment of the employees both medical and non medical, and selection of doctors. Apollo was also to provide an exhaustive set of instructions and guidelines on the management of the clinic to the franchisees and it was responsible for monitoring the quality of the services delivered at these clinics.

While on paper the model looks perfect, it has some serious infirmities.

A franchised operation by definition has to be a replication of an existing successful model. In Apollo’s case, they had nothing to show in the area of Primary Healthcare. They used to run a clinic in Mumbai, which they owned. Just about the time Apollo decided to go the franchise route, their own clinic shut shop. It was losing money hand over fist and the management decided to shut it down.

In the franchised model that was now envisaged Apollo had no financial stake. The money was to be put up by the franchisee, he was to bear all the costs including a revenue share with Apollo and it was not clear how Apollo will contribute to bringing in new patients to the clinic. It was expected that Apollo’s name itself will pull in patients. Thus the franchisee was to fend for himself as far as developing the business was concerned. Apollo could have contributed by investing in the brand ‘Ápollo Clinics’ and by forcing some of its leading doctors to run the OPD’s from the franchised clinics. Apollo made lofty promises of investing millions in the brand but just didn’t. As far as doctors were concerned, some feeble attempts were made to get Apollo doctors to attend these clinics but hardly anything materialised. The problem really was that in Apollo system the senior doctors are not paid firm salaries and they work on a revenue share model. Thus, Apollo’s control over these doctors is minimal. The senior doctors with a busy practice had no reason to sit in the newly opened Apollo Clinics, which in any case did not have any patients of their own.

The selection of the franchisees too threw up issues. The franchisees were largely businessmen with hardly any experience of healthcare. Neither did they have any particular love or passion for the healthcare business. I remember meeting and offering franchises to computer hardware merchants, aluminium dealers, a golf ball manufacturer, a real estate player and the like. All of them were driven purely by a profit motive. Some also saw healthcare as a more respectable business for their children. We sold the franchises indiscriminately, (at least in the beginning) to anyone willing to put up the money. A network was thus born that had no glue except the brand name that each franchise shared with the other.

The biggest casualty in all this was of course the quality of healthcare services that each clinic rendered. There was no uniformity as each franchisee left to fend for himself became increasingly desperate for revenue. He hired doctors on his own many of dubious quality, started offering cuts for referrals, set his own prices and started indulging in all kinds of practices that would help him get the extra money that he needed to stay afloat. As most of these franchises were not businessmen with deep pockets, they were willing to cut corners as their very survival was at stake. In-spite of all this many had to close down operations.

Apollo gradually lost control over these franchises. Since, it did not add any value to the franchise’s life he decided not to pay the monthly royalty. Many refused access to Apollo personnel on their premises and are now pretty much operating as stand-alone entities. They continue to use the Apollo name, as that is the only thing, which adds value to their operations.

Creating a franchised healthcare network is fraught with danger. Apollo failed by not first establishing a successful chain of primary healthcare centres of its own. It had no proven learnings in that space and it undertook to make money at its franchisee’s cost. It lost the trust of not only its franchisees, but also of many of its patients who certainly expected a lot better from Apollo.

Pic courtesy The Apollo Clinic website

A Neurosurgery In Delhi-A Tale of Two Hospitals

A couple of weeks ago an old friend of mine called from Indore. His father in law, who was visiting his family in the US has had a seizure. His wife had rushed him to a local hospital, where they found a large tumour in his brain. The tumour measuring more than 5 cms was likely to be benign. The patient, a sprightly 68 years old has never had any illness, has never seen the inside of a hospital and the family was very concerned about this sudden turn of events.

Now I have known Asit for a long time. We went to school together. After the school got over we drifted apart. Asit migrated to the US, while I settled down in Delhi. We lost touch with each other till we found ourselves connected over the wired world of e-mails and the ubiquitous Facebook. Asit subsequently started a yahoo group and many of us got in touch with each other after almost 20 years.

Asit over the phone sounded very worried. He was in India on work, his in-laws were in the US with his wife (their daughter) and a medical crisis was facing them. His father in law has been recommended surgery and Asit wanted to know everything about the tumour, the treatment options, the hospitals in India, where the surgery could be done, the prognosis post surgery, the mortality rates and who were the best neurosurgeon whom he could get an opinion from. I recall I was in Mumbai when Asit spoke with me first and I promised all possible help.

Asit, soon had his wife send me the patient’s scans and reports from the US. On Asit’s request I met a neuro-surgeon in the Lilavati hospital in Mumbai. The surgeon gave me time in the evening and explained about the surgery. However, this surgeon for some reason did not inspire trust. He seemed almost bored through out our interactions, it was as if I was a smart alecky patient attendant and he the big reluctant surgeon, doing me a great favour by discussing the impending surgery.

On my return to Delhi, I set up a meeting with Dr. Ajeya Jha, the chief of neuro surgery at the newly opened Medanta Medicity in Gurgaon. I have known Dr. Jha from my days at Max Healthcare,where he was the chairperson of the Institute of Neuro Surgery. Dr. Jha, went through the reports and the scans, confirmed that the patient had no choice except surgery and answered all my questions patiently. He was happy to speak with Asit over the phone and allay his apprehensions as well. He also assured Asit that the surgery in India at Medicity was as safe as any where else in the world.

In the meanwhile Asit’s wife Sudha sought a medical opinion at Stanford in the US. She met with the doctors in the US, and discussed the option of surgery in India. They were reassured that surgery in India was a safe option and the outcome was expected to be just as good as any centre in the US.

Now that we were making progress I requested Asit to travel to Delhi to meet Dr. Jha. I also told him that, while in Delhi he must also meet at least one more neuro-surgeon so that he can exercise choice. I made enquiries and was referred to Dr. Rana Patir, the chief of neurosurgery at Max Healthcare.

On March 31st, the patient landed in Delhi. Asit too arrived from Indore and in the afternoon we met Dr. Jha at the Medicity. Asit was very impressed with the hospital. It looked almost as good as any hospital that he had seen in the US. Dr. Jha spent an hour with Asit and his close relatives who had also arrived in Delhi for the surgery. They bombarded Dr. Jha with questions, which he answered patiently, explained in great detail about the surgery, the odds of complete recover (95%), partial recovery (99%) and mortality 1%. He drew diagrams to explain the situation. Not once did he sound either overconfident or tentative. Dr. Jha laid it out as it was, yet inspired confidence in his and his team’s skills.

After our meeting with Dr. Jha, we drove to Max for an appointment with Dr. Patir, which was fixed for 6 in the evening. On reaching the hospital we were informed that Dr. Patir was in surgery and would see us in 15 mins. We waited outside his OPD amongst a bunch of patients, apparently all waiting for him. Our wait grew from 15 mins to almost 2 hours, and there was no sign of Dr. Patir. I called up the hospital administrator, who is a friend of mine from our days together at Max. He too was acutely embarrassed and advised me to write a complaint and promised to raise the matter internally.

Finally as we were about to leave in disgust, Dr Patir sauntered in. A wild rush amongst those waiting outside his office to meet him ensued. After about 2.5 hours of waiting we were ushered in to meet Dr. Patir. He too went through all the reports, answered all our questions, gave us time and the same kind of odds that Dr. Jha had given. Since, I had to return to work and I had been delayed waiting for Dr. Patir, I left Asit, while they were still Dr. Patir.

The next day Asit called me up. They had decided to have the surgery at the Medicity. He felt more comfortable with Dr. Jha, who had given them more time and treated them with great courtesy (not that Dr. Patir was rude, he just felt Dr. Patir was too busy). Asit also felt that Dr. Jha appeared more keen on treating his father in law, had given them personalised attention and had been very honest and forthright with them.

Mr. Jain underwent successful surgery at Medicity two days later and made a quick recovery. The cost of surgery in the US was approx. USD 160000 after the factoring in all the discounts that Asit was entitled to. At Medicity the cost was less than USD 15000.

As far as Max is concerned, they lost a patient to a newly opened rival because Asit did not have enough patience to put up with Dr. Patir (who by all accounts is a very good surgeon) and Medicity honestly tried a lot harder.

I have the changed the names of the patient and his relatives to protect their privacy

Why do the Hospitals need to invest more in Advertising?

Hospitals in India hardly advertise. Most of them look at advertising as an unnecessary expense and keep it minimal. This really need not be so. Looked from another angle, advertising for a hospital can be a critical investment, which allows it to differentiate its services, educate customers about its core beliefs, introduce new products and services and help gain new customers. Unfortunately, in India hospitals believe that customers do not appreciate hospital advertising and may even be put off by it. Many hospitals, who are doing well do not see the need for advertising. With occupancy rates high, the hospitals feel they are wasting money by advertising. Little do they realise that advertising quite often is not only about getting more patients.

To make matters worse, whatever little advertising one sees is mostly inane and dull. The communication usually bears the imprint of too many cooks adding different flavours to the advertising, making it a weird medley of pictures, long copy and a strange layouts. The marketing teams in the hospital are forced to accommodate various view opinions (that of the hospital COO/CEO, the heads of medical departments, other leading physicians, the sales head, and sometimes the owner of the hospital ) to arrive at a piece of communication, which is usually a disaster from a marketing communications point of view. While, this piece assuaged inflated egos, ensures gory pictures (usually reflecting some landmark surgery) in the ads, highlights achievements of some or the other doctors, it fails in its primary purpose of connecting with the end-user.

Here are a few reasons, why hospitals should look at their advertising a lot more seriously and spend money wisely in connecting with their customers.

Core Beliefs and Positioning

A hospital must advertise its core beliefs through a well thought of brand campaign. It is imperative for customers to know what their hospital stands for, what its core values are and how does it strive to stay true to those beliefs. Thus, if a hospital professes to provide ‘Total Patient Care’as a consumer I would love to know, what it means and what all can I expect from the hospital. Similarly if a hospital is positioned as a ”cutting edge technology” centre I would like to know what that means to me as a customer. A hospital must stand for something in the consumer’s mind. I am not sure, our big hospital brands Apollo, Fortis, Max and Wockhardt (now part of Fortis) have been able to establish any kind of distinct identity in the consumer’s mind.

Products and Services

A hospital offers a multitude of services. Customers need to know about them and hence advertising is a good way of keeping customers informed. New services keep getting added from time to time and the hospitals need to keep their customers updated. Recently Max Healthcare started its cancer services. All that they did was release a solitary advertisement, welcoming the new Chairman of Cancer services!!! The ad was also supposed to serve the purpose of informing the customers about the commencement of cancer care services at the hospital. Wouldn’t it make greater sense to announce the commencement of a service with a nice campaign and if needed also feature the medical leader/team in the ads?

Hospital Launch

A new hospital commencing operations needs high decibel advertising. Artemis did this well, when we launched the hospital. We had large bill boards in Gurgaon, a fairly heavy presence in the local print media and local community engagement through ‘fam visits’ to the hospital. I recall Max Healthcare during their launch also did a fairly well orchestrated multi-media campaign. However, many hospitals too try to save money by launching quietly and hoping the customers will come through the word of mouth or through doctors pulling in their existing customers. I believe, these are sub-optimal ways of launching the hospital’s services and an old-fashioned media blitzkrieg works the best.

Renewing Existing Services

Sometimes it is necessary that a hospital ‘renew’ its existing services. These days, I am seeing some bill boards near my residence advertising Apollo’s new Knee Clinic. The communication is targeted at the elderly, informs about the new Knee Clinic, which offers Knee Replacement services at the hospital. Now, Apollo hospital has been doing knees for a long time, however the communication is trying to repackage the service and relaunch it. Unfortunately, There are just two bill boards and, while the intent is laudable, the hospital is being very stingy. Similarly, while in Bangalore recently I came across a ‘Short Stay Surgery’ campaign by Wockhardt Hospitals. Again the effort seems to be to reposition their Laparoscopic Surgery services in a customer friendly matrix, but the money behind the campaign appeared too little to make any significant impact. Other hospitals too need to often ‘renew’ and repackage their services smartly.

Driving Traffic

Hospitals can drive traffic to their OPD’s through innovative offers. In fact the bulk of hospital advertising today focuses here. A free Cardiac Camp around the World Heart Day is routine. Similar camps and offers in other specialities help drive traffic to the hospital OPD’s. The problem here is that hospitals do these sporadically, without adequate planning and often as band-aid solutions to transient OPD traffic related issues. Tactical campaigns need to be more consistent and better planned to yield optimal results.

Educating Customers

Wouldn’t it be wonderful if a hospital did an educational campaign about let us say heart disease or diabetes or any other lifestyle diseases. The campaign should aim to educate customers about the disease, its symptoms, treatment options, success rates, technology available and the medical expertise available to treat the disease. The objective should be to inform the customers, help them ask the right questions and thus make the right choices. Unfortunately, none of our hospitals including the big chains are willing to invest in patient education simply because the returns are relatively long-term.

Pic is indicative.

The Rural Doctors

In a bid to provide primary healthcare services in rural India,the Ministry of Health of the Government of India has proposed a 3.5 years abridged medical course. The idea is to churn out doctors willing to work in rural communities faster. The proposal mooted by the health minister Ghulam Nabi Azad has drawn mixed reactions from various quarters. Many have argued that by introducing an abridged diploma course the government will be playing with the lives of the rural folks. The essential argument is that even the basics of medicine can not be taught in such a short period of time. Others have taken a contrary view, pointing out that replacing today’s rural quacks with doctors having a basic formal medical education will be a huge plus.

In rural India, where more than 60% of India lives access to good quality healthcare is minimal. The government has spent millions of rupees in trying to provide primary healthcare in these areas and has met with little success. The twin problems of medical infrastructure and trained people has stymied government effort for long. Of these, it can be argued that the infrastructure problem is rather easily taken care of, the government just has to find the will power and the money to build primary health centres. The bigger problem is of finding qualified and trained doctors to work in rural areas.

Forcing newly minted doctors from government-run medical colleges, which offer subsidised education is a sub-optimal solution. These doctors hailing from large urban centres have no desire to work in rural, underdeveloped areas, where they can not possibly have the lifestyle that they are used to. The divide between Bharat and India has ensured that the chasm is too big to bridge and these doctors and their patients have almost nothing in common.

In rural India today, primary healthcare services are largely provided by a class of quacks, masquerading as doctors. Illiterate rural folks have no idea of the knowledge or formal qualifications of these ‘doctors’. They do not have the courage or the wherewithal to find out the antecedents or the past experience of these physicians and the entire system works on blind faith. Usually, these quacks have some knowledge of medicine largely acquired by having worked as assistants to doctors in big cities. Thus, they are able to continue the charade by prescribing commonly used OTC medicines and some wide spectrum antibiotics, for almost all ailments. Many people recover from common ailments, those who do not or grow steadily worse are referred to real doctors in nearby towns and cities.In remote and far-flung areas, things are even worse. Faith healers and babas of various hues treat people using ’jhaad-phoonk’, which are nothing but ancient pagan rituals. This is the terrifying reality of the 21st century rural India.

In this context, it makes eminent sense to have a cadre of rural doctors with some formal medical education. They would be able to provide far superior care than what is presently available in rural India. That the government proposes to hire rural youths in this program will ensure that these doctors continue to live and serve in their own communities. Unlike, their urban counterparts, these doctors do not run the risk of being fish out of water in this environment.

The government should now swiftly move forward towards evolving a mechanism for setting up rural medical colleges and lay down guidelines for enrolling rural youths in these courses. It should set up a few rural medical institutes and a regulatory body to regulate the proposed system. The government must also apprentice these rural doctors in government hospitals for at least 6 months so that they learn the practice of medicine from senior and more qualified doctors.

This solution I know is far from ideal. It also smacks of a certain class bias (more qualified doctors for slick city dwellers, under-qualified and not as well-trained doctors for poor rural folks), but such is the reality of the urban and rural life in India that even an idea like this has its distinct merits.

The Government's Apathy to Healthcare in India

The Union budegt presented last month by the finance minister, Pranab Mukherjee, is hugely disappointing for the healthcare sector in the country. For many years now people associated with healthcare in the country have been waiting for big-ticket reforms in the sector, but the government has been turning a deaf ear. This year too, the story is no different.

The healthcare services in the country are not only woefully inadequate but also unevenly distributed. The healthcare industry, which is hugely dependent on private enterprise is just not attracting enough investments. Setting up and managing a hospital till it breaks even and makes money requires huge upfront investments. Presently, India has 860 beds for a million people, way below the WHO's norm of 3960 beds for a million people. Studies by E&Y and KPMG have indicated that India needs to add 100000 beds per year for the next 20 years to reach close to this figure. This alone entails a spend of Rs. 50000 Cr. per annum. Compare this with what the government proposes to spend on healthcare in the next financial year, Rs. 22300 Cr. While this is 14% more than what the government spent last year, this amount is clearly insufficient.

The National Rural Health Mission, the flagship government programme for providing healthcare services in rural areas is riddled with inefficiencies. The government-run Primary Healthcare Centres are usually understaffed, ill-equipped and provide the most basic level of healthcare. Rural and semi urban India also needs good professionally managed secondary and tertiary care hospitals, which provide reasonably good quality healthcare at affordable rates. It seems that the government does not have the will power or the resources to usher in healthcare reforms.

Amazingly, the private sector entrepreneurs are willing to step in and bridge the gap. All they need is a little help from the government in the form of tax holidays, duty reduction or abolition of duties on medical devices, easy availability of funding from government institutions at soft rates, longer payback periods and land at concessional rates. The government should also set up a regulatory body, a watchdog, which will keep an eye on hospitals being set up through this mechanism. The watchdog is critical as it will establish guidelines for setting up the hospitals, monitor progress, ensure quality through regular audits, lay down a fair pricing mechanism and in general ensure that the private sector, while availing of government policy benefits delivers on the promise of efficient, good quality and easily accessible care.

This is really not too difficult to achieve. Look at how private participation has revolutionized telecommunications in our country. Today India has more than half a billion mobile phone connections, the tariffs are the lowest in the world and even remote, far-flung and fairly inaccessible areas are connected (I had my phone working in the Nubra valley in Laddakh). The phones generally work, the services are efficient and the private sector companies, who had the foresight to start early are making profits. Some are even planning to go global and compete with the best in the world. The TRAI, which is the government watchdog is seen as an impartial and fairly efficient body, doing its job of advising the government on policy matters and ensuring compliance and a level playing field amongst all the operators.

No country can progress and aspire to be an economic superpower unless its citizens have access to good quality healthcare services. Considering India's size and a population of over a billion people, (the majority living in rural areas), it is imperative that the government kick-start reforms in this critical area sooner than later. If no significant policy initiatives have been announced this year, can the healthcare industry bodies (like those associated with CII and FICCI) lobby with the government, initiate debate and fuel informed discussion amongst all stake holders so that public opinion can be rallied in favour of these reforms.

Healthcare services impact the health of the nation. It is time all the healthcare stakeholders including the government sat together to prepare the blueprint for the next generation healthcare services for the country. This is very important because, unless we have robust, universally accessible, reasonably priced healthcare services for our citizens, all our claims about being an economic superpower will remain hollow and truly meaningless.