Skip to comments.Health care in India Lessons from a frugal innovator
Posted on 06/12/2009 12:06:49 PM PDT by swarthyguy
ENTER the main cardiac operating-room at Bangalores Wockhardt hospital on a typical morning, and you will find a patient on the operating table with a screen hanging between his head and chest. On a recent visit the table was occupied by a middle-aged Indian man whose serene look suggested that he was ready for the operation to come. Asked how he was, he smiled and answered in Kannada that he felt fine. Only when you stand on a stool to look over the screen do you realise that his chest cavity has already been cut open.
As the patient was chatting away, Vivek Jawali and his team had nearly completed his complex heart bypass. Because such beating heart surgery causes little pain and does not require general anaesthesia or blood thinners, patients are back on their feet much faster than usual. This approach, pioneered by Wockhardt, an Indian hospital chain, has proved so safe and successful that medical tourists come to Bangalore from all over the world.
This is just one of many innovations in health care that have been devised in India. Its entrepreneurs are channelling the countrys rich technological and medical talent towards frugal approaches that have much to teach the rich worlds bloated health-care systems. Dr Jawali is feted today as a pioneer, but he remembers how Western colleagues ridiculed him for years for advocating his inventive awake surgery. He thinks that snub reflects an innate cultural advantage enjoyed by India.
Unlike the hidebound health systems of the rich world, he says, in our countrys patient-centric health system you must innovate. This does not mean adopting every fancy new piece of equipment. Over the years he has rejected surgical robots and keyhole surgery kit because the costs did not justify the benefits. Instead, he has looked for tools and techniques that spare resources and improve outcomes.
Shivinder Singh, head of Fortis, a rival hospital chain based in New Delhi, says that most of the new, expensive imaging machines are only a little better than older models. Meanwhile, vast markets for poorer patients go unserved. We got out of this arms race a few years ago, he says. Fortis now promises only that its scanners are world class, not the newest.
Mr Singh is not alone in thinking that many firms in the rich world are looking at innovation the wrong way. Paul Yock, head of the bio-design laboratory at Stanford University, which develops medical devices, argues that medical-technology giants have looked at need, but been blind to cost. Amid growing concern about runaway health spending, he thinks the industry can find inspiration in India.
Poverty, geography and poor infrastructure mean that India faces perhaps the worlds heaviest disease burden, ranging from infectious diseases, the traditional scourge of the poor, to diseases of affluence such as diabetes and hypertension. The public sector has been overwhelmed, which is not surprising considering how little Indias government spends on health as a share of national income (see chart). Accordingly, nearly four-fifths of all health services are supplied by private firms and charitiesa higher share than in any other big country.
In the past that was more a reflection of the states failure than the dynamism of entrepreneurs, but this is changing fast. Technopak Healthcare, a consulting firm, expects spending on health care in India to grow from $40 billion in 2008 to $323 billion in 2023. In part, that is the result of the growing affluence of Indias emerging middle classes. Another cause is the nascent boom in health insurance, now offered both by private firms and, in some cases, by the state. In addition, the government has recently liberalised the industry, easing restrictions on lending and foreign investment in health care, encouraging public-private partnerships and offering tax breaks for health investments in smaller cities and rural areas.
Cheaper and smarter This has attracted a wave of investment from some of Indias biggest corporate groups, including Ranbaxy (the generic-drugs pioneer behind Fortis) and Reliance (one of Indias biggest conglomerates). The happy collision of need and greed has produced a cauldron of innovation, as Indian entrepreneurs have devised new business models. Some just set out to do things cheaply, but others are more radical, and have helped India leapfrog the rich world.
For years Indias private-health providers, such as Apollo Hospitals, focused on the affluent upper classes, but they are now racing down the pyramid. Vishal Bali, Wockhardts boss, plans to take advantage of tax breaks to build hospitals in small and medium-sized cities (which, in India, means those with up to 3m inhabitants). Prathap Reddy, Apollos founder, plans to do the same. He thinks he can cut costs in half for patients: a quarter saved through lower overheads, and another quarter by eliminating travel to bigger cities.
Columbia Asia, a privately held American firm with over a dozen hospitals across Asia, is also making a big push into India. Rick Evans, its boss, says his investors left America to escape over-regulation and the political power of the medical lobby. His model involves building no-frills hospitals using standardised designs, connected like spokes to a hub that can handle more complex ailments. His firm offers modestly priced services to those earning $10,000-20,000 a year within wealthy cities, thereby going after customers overlooked by fancier chains. Its small hospital on the fringes of Bangalore lacks a marble foyer and expensive imaging machinesbut it does have fully integrated health information-technology (HIT) systems, including electronic health records (EHRs).
New competitors are also emerging. A recent report from Monitor, a consultancy, points to LifeSpring Hospitals, a chain of small maternity hospitals around Hyderabad. This for-profit outfit offers normal deliveries attended by private doctors for just $40 in its general ward, and Caesarean sections for about $140as little as one-fifth of the price at the big private hospitals. It has cut costs with a basic approach: it has no canteens and outsources laboratory tests and pharmacy services.
It also achieves economies of scale by attracting large numbers of patients using marketing. Monitor estimates that its operating theatres accommodate 22-27 procedures a week, compared with four to six in other private clinics. LifeSprings doctors perform four times as many operations a month as their counterparts do elsewhereand, crucially, get better results as a result of high volumes and specialisation. Cheap and cheerful really can mean better.
But there is more to Indias approach than cutting costs. Its health-care providers also make better use of HIT. According to a recent study in the Journal of the American Medical Association, fewer than 20% of doctors surgeries in America use HIT. In contrast, according to Technopak, nearly 60% of Indian hospitals do so. And instead of grafting technology onto existing, inefficient processes, as often happens in America, Indian providers build their model around it. Apollos integrated approach to HIT has enabled the chain to increase efficiency while cutting medical errors and labour. EHRs and drug records zip between hospitals, clinics and pharmacies, and its systems also handle patient registration and billing. Apollo is already selling its expertise to American hospitals.
Eye on the prize A casual visitor to Madurai, a vibrant medieval-temple town in southern India, would not think it was a hotbed of innovation. And yet that is exactly what you will find at Aravind, the worlds biggest eye-hospital chain, based in the town. There are perhaps 12m blind people in India, with most cases arising from treatable or preventable causes such as cataracts. Rather than rely on government handouts or charity, Aravinds founders use a tiered pricing structure that charges wealthier patients more (for example, for fancy meals or air-conditioned rooms), letting the firm cross-subsidise free care for the poorest.
Aravind also benefits from its scale. Its staff screen over 2.7m patients a year via clinics in remote areas, referring 285,000 of them for surgery at its hospitals. International experts vouch that the care is good, not least because Aravinds doctors perform so many more operations than they would in the West that they become expert. Furthermore, the staff are rotated to deal with both paying and non-paying patients so there is no difference in quality. Monitors new report argues that Aravinds model does not just depend on pricing, scale, technology or process, but on a clever combination of all of them.
C.K. Prahalad and other management gurus trumpet examples like Aravind, but do the rich countries accept that they could learn from India? Unsurprisingly, some reject the notion that Americas model is broken. William Tauzin, head of Americas pharmaceutical lobby, warns that regulatory efforts to cut costs could stifle life-saving innovation. Sandra Peterson of Bayer, a German drugs and devices giant, stoutly defends the industrys record. She argues that overall cost increases mask how medical devices, like cars or personal computers, give better value for the money over time. Diabetes monitors and pacemakers have improved dramatically in the past 20 years and have fallen in pricebut costs have gone up because they are now being used by more patients.
But those examples are exceptions. Many studies show that Americas spending on health care is soaring, yet its medical outcomes remain mediocre. Mark McClellen of the Brookings Institution, an American think-tank, says that a big problem is the overuse of technology. Whether or not a scan is needed, the system usually pays if a doctor orders itand the scan might help defend the doctor against a malpractice claim. The root cause is not greed, but tremendous technological progress imposed upon a fractured health system, says Thomas Lee of Partners Community HealthCare, a health provider in Boston.
Dr McClellen, a former head of Americas Food and Drug Administration, points out that other innovative industries often sell new products at a loss, and recoup their investments later. In genuinely competitive industries, innovators are rarely rewarded with the cost plus reimbursements demanded by medical-device makers for their gold-plated gizmos.
That is why Stanfords Dr Yock wants to turn innovation upside down. He has extended his bio-design programme to India, in part to instil an understanding of the benefits of frugality in his students. He believes that Indias combination of poverty and outstanding medical and engineering talents will produce a world-class medical-devices industry. Tim Brown, the head of Ideo, a design consultancy, agrees. In the past, he notes, health bosses thought all devices had to be Rolls-Royces or Ferraris. But cost matters, too. Pointing to another recent example of Indias frugal engineering, he says: In health care, as in life, there is need for both Ferraris and Tata Nanos.
If anyone wants to operate in my chest cavity, please knock my butt out!
India innovates and we Obaminate! India encourages private investment and we denounce profits in health care. India has functioning markets for health care and we resort to price controls and rationing. The roles have certainly reversed. India used to be a backwater of Marxist control. Now we headed to Marxist control.
Lol, that was my first reaction too!
Here, watch the surgery at the same hospital:
Something to keep in mind is that a lot of the ever-less-intrusive medical technology demanded in America is to reduce the potential for cosmetic disfiguration. In India, looks matter less than living, so simpler, cheaper techniques can be employed.
That is a beautiful thing. Just amazing.
This kind of surgery would leave about the same length of cut on the chest, using other methods too.
The doctor in the video I posted above actually mentions endoscopic surgery for the procedure.
The law of torts in India
There has been an urgent need in India to reform various sectors of law and torts continue to be ignored, mostly for the reasons of high costs of tort litigation.
Tort is the area of law where in response to a private or civil wrong or injury the courts provide the remedy of allowing a lawsuit for (usually monetary) damages. Thus, the goal is to restore the victim to his or her former condition. It has been suggested that the law of torts is developed in India in a scattered manner, but yet it provides for very effective remedies. Most of Indian tort law was developed after the British colonization. The continued underdevelopment of Indian tort law is surprising given the impressive commitment to both compassion and comprehensiveness embodied in the Indian constitution ratified in 1950 (three years after independence from Britain).
Tort law is said to be a development of the old maxim ubi jus ibi remedium (Every right needs a remedy). Are Indians simply possessed of fewer rights in this important sphere? What are we to make of this underdevelopment regarding a fundamental question in almost all systems of law- how to make the victim whole, how to provide reparation? The law of torts as administered in India in modern times is the English law as found suitable to Indian conditions and as modified by Acts of the Indian Legislature. The law of torts or civil wrongs in India is thus almost wholly the English law, which is administered as rules of justice, equity and good conscience. In English law, a tort is a civil wrong, as distinguished from a criminal wrong. The term tort comes from the Latin tortus, meaning crooked. Some wrongs are the concern of the state, and so the police can enforce the law on the wrongdoers in court - in a criminal case. The police does not enforce a tort. It is a civil action taken by one citizen against another, and tried in a court in front of a judge (only rarely, in certain cases of defamation, with a jury). Certainly, some of the features of the law of torts are which were developed in England are absent in India. The Indian courts therefore, apply those principles to match the situations in India. This means there is an altercation from the British law to suit the Indian conditions. This fact is quite appreciated because there is a difference in the societies and systems of Britain and India. Tort law is not codified in India. This means whenever an exigency arises, a precedent shall be set up to take care of the peculiar situation. This definitely is a good solution to cope up with civil matters in the largest democracy on the planet. It has also been noted in the Union Carbide Case, that Section 9 of the Code of Civil Procedure, which enables a Civil Court to try all suits of a civil nature, impliedly confers jurisdiction to apply the law of torts as principles of justice, equity and good conscience. This definitely is, providing a forum to try civil wrongs and making them a miscellaneous category. This provides the courts with a wide array of jurisdiction. Nuisance, negligence, etc. are wrongs of a different nature. It is definitely agreed that the simpler torts need highlighting, but the problem again remains the same. Litigation. To overcome the same there should be courts specifically set for these small offences or even bigger ones, of civil nature.
The judicial activism which has been present in certain cases like the UCC Case, or the Nilabati Behera case, are typical examples of development in constitutional tort. This outlook has profoundly influenced the direction which tort law has taken. The concept of sovereign immunity has been axed; the vicarious liability of the state concept has been recognized in several cases. Henceforth, it is very much evident that the magnum of the wrong, the parties involved, and the gravity of the situation has decided (and continue to do so) the delivering of judgments relating to torts. This fact shows that the judiciary is in fact, active on setting precedents on tort law. There has been a scattered array of acts and statutes relating to different kinds of tort, like the Motor Vehicles Act, 1988 (it was also enacted in late 80s) and Water Pollution Act, Air Pollution Act etc. The Environment Protection also came up, as late as 1986, as an after effect of the Bhopal Gas Tragedy.
A land mark case needs mention here, because of the progressive approach of the Indian judiciary in this regard. A more stringent rule of strict liability than the rule then the rule in Rylands v. Fletcher was laid down by the Supreme Court in M.C.Mehta v. Union of India. The court gave the reasoning that the old rule of the common law did not meet the modern techniques of science and industrial society. There is a need to depart from that rule whereby the industries ought to be aware of their responsibility, if they are taking benefit out some hazardous business. This approach of the Supreme Court clearly shows that there is no need for a settled or a model tort law structure in India. Its so-called branches are now assuming different dimenstions. Thus, there is a present grund norm or a basic covenant, which directs tort law. That grund-norm may be located in the common law.
A plethora of debates and agitations were unleashed after the Bhopal Gas Tragedy and environmental legislations came in. The crux remains the there has been an importance given to the issues of global importance like environment protection, which also finds a place in the law of tort. Assault, battery etc. are smaller torts and there have been provisions incorporated for them either in the CPC or the CrPC. Thus, there is no need for a specific legislation dealing with such small civil wrongs.
Another thing, which needs highlighting at this juncture, is the Consumer Protection Act, in India. It has assumed a different jurisprudence altogether and has become a different stream in itself. It also provides for trying of medical negligence cases before a consumer court or forum. It is a vitalizing point again, that since it has assumed a stature and that of a very high degree, it has become important. And, to the extent that, a legislation was indeed enacted for the same. This fact clearly shows that the legislature has provided for effective remedies for civil wrongs, and thus the law of tort as a sum total for debating purposes only, and it wouldnt be necessary to give a lot of importance to it - like codifying it, as some argue.
The law on nuisance does provide for public nuisance and private nuisance. It has to be continuous to bring up a claim. Private nuisance can be considered when there has been a substantial nuisance and unreasonable interference. Bringing on claims merely on ordinary discomforts would definitely be a futile litigation and it would overlook the practicalities of life. On this ground it would be quite wrong to say that torts are being overlooked. It must be noted that the court, while interpreting S.133 of the CrpC has indeed allowed private claims as well.The court did say that the language used by the said section does not necessarily mean public or private nuisance.
Now, with reference to nuisance, there has been a clear distinction via several cases between, environmental nuisance and tort nuisance. Now, nuisance has been given, a more criminal tilt to it. It is evident that the remedy provided in the CrPC or the IPC, has been effectively exhausted. The classic example being, the Ratlam Municipality Case.When it comes to nuisance and as a civil wrong (private nuisance to be more specific), remedies available are scarce, and the injured parties are often disinterested. The tort litigation in India is no where as compared with that of the U.S.A or for that matter, the country which has given India its uncodified tort law, Britain. There is a proper jury in certain cases of defamation in England, while in India; it is not taken too seriously. Defamation has been made a criminal act too. The system in England is quite different from India. They run on precedents. Thus it would be wise to cut down the court fee to appreciate more legislation, rather than giving much importance to the law of tort.
The development of tort law is evident in the law relating to nuisance as well. Principles, such as the polluter pays principle are now being accepted through various judicial pronouncements in India.
There has been a wide acceptance of cases going to the Supreme Court via writ petitions or public interest litigations. This is a more effective and expeditious remedy available. How often it has been seen, that the Supreme Court has admitted writ petitions under Article 32 of the Constitution of India.The courts have awarded compensation in such cases as well. Thus, the courts have tried to provide an effective forum and method to the citizens. Now, in matters like environment, in which the claimants problems used to be the prerogative of the State Pollution Control Board. It was upon the Board to approach the court. The situation has changed now. The courts have recognized citizen suits in such matters too, thus opening a new way for the common men to approach the courts. Another reason why the Supreme Court has become a remedy provider is that, there are very few problems of locus standi. Most of the cases have been dispensed off in a very tactful and justifiable manner.
Taking about compensation, Section 357(1) of the CrPC permits a court, while sentencing an accused to fine, to award compensation out of the fine to any person for loss or injury caused by the offence when compensation is in the opinion of the court, recoverable by such person in a civil suit. Further, Section 357 (3) provides that a court can ask the accused (apart from the fine) to indemnify the victim, by way of compensation. The point is that, the courts and the legal system does provide for alternative remedies and a wide range of remedies. Then why is there a need to give importance to tort, as a single entity?
There is also a provision for injunction in the Code of Civil Procedure as well as the Specific Relief Act. An injunction is an order of a court restraining the commission, repetition, or continuance of a wrongful act of the defendant. An injunction may be granted to prevent waste, trespass, or the continuance of nuisance to dwelling or business houses, to right of support, to right of way, to highways, to ferries, to markets etc. Thus there is a mechanism available to sort out or look in to trifles as well. These small torts can also be taken care of, by the two Acts mentioned above. The Specific Relief Act also provides for restitution of property. Thus a person who is wrongfully disposed of immovable property or of specific movable property is entitled to recover the immovable or movable property, as the case may be. All these examples exhibit a wide range of legal issues and their remedies that are indeed available in the procedural (as well as substantive) laws of this country.
Now, coming to the law relating to defamation in India, there is a diversion from Britain. The common law rule that slander is not actionable per se has not been followed in India, except in a few decisions. The reason given is that the rule is not founded on any obvious reason or principle, and that it is not consonant with justice, equity and good conscience. Both libel and slender are criminal offences under s. 499 of the Indian Penal Code and both are actionable without proof of special damage. Thus, there is an option available for defamation in India, to go for a civil remedy or a criminal one. This again exemplifies the ease with which the judiciary has molded the different branches of tort law in to the Indian legal system.
Finally, we would be inclined to conclude that it is quite obvious that there is no need to centralize the law of tort. Nuisance, negligence, defamation etc. are independent of each other and there are different remedies available for them, as we have seen. These remedies are more effective and wide in nature, but for the cost of litigation that needs to be brought down.
(The author is a student at Gujarat National Law University in Gandhinagar.)
I can barely sit still for a hair cut much less surgery.
Thanks to the bloodsucking leeches in the legal profession, physicians spend billions practicing needless defensive medicine, and billions more sticking with the status quo rather than trying new techniques.
Funny, I was just talking with someone about some oddball litigation and waxed nostalgically about President Bush’s call for tort reform way back when.
This case was funny - outpatient left hospital after a colonoscopy, patient had a car crash, cop on his way to the scene has a crash also.
Cop’s suing the hospital for letting the guy out too early.
According to the US Trial Lawyer’s group, India is woefully understaffed. Assuming that’s what they’d say.
I am not sure that I would like being awake under major surgery, but the Indians have a cultural advantage. They seem to respect tricks like lying on a bed of nails, or walking on hot coals.
But seriously, I admire their common-sense innovation. Everything indicates that India is advancing very rapidly. One might ask, why is India advancing, and the Muslim countries of Pakistan and Bangledesh are essentially going nowhere?
I favor the theory that family structure plays a big part in the cultural forms which determine competitive success. The best is the nuclear family, or alternatively the tight Confucian family model, which has well defined roles of responsibility. Less effective is the “extended family” model found in the more backward parts of India, because many of the extended family are out-of-work lay-abouts, who diminish the rewards of the harder-working family members. Third is the Islamic model, which constricts the creativity of women, and distorts their natural role as mothers, is generally anti-intellectual, and glorifies violence.
The single-parent family is the weakest form of all. The end-result example is Haiti, poorest country in the Western Hemisphere, where about 5% of the children are in two-parent families. Marriage is virtually ineffective as a social force in Haiti.
>>Everything indicates that India is advancing very rapidly
In certain aspects the Chinese are far ahead, like in the lack of malnourishment as found in India. However, totalitarian societies have advantages in imposing all kinds of solutions. India’s political gabfest culture, while often slow and frustrating, also imposes the constraints of democracy, solutions take time, but are in turn validated by the process.
India’s still rigourous family structure is proving flexible enough to allow the urban professionals to have significant independence and choices in their lives while still adhering to regular, if not always joyous or pleasant family interactions.
yeah and the wages of nurses and doctors is pathetic in India. they get educated here, scam the student loans, and then go back there.
Instead of crowing about this you ought to be searching for the horror stories from Idian hospitals that make the Brits look sane ( and there are plenty).
It is damned near impossible to get ANYONE to respond to you once your srugeries are done. If something goes wrong, tough you lose. Moreover they do not have some of the really critical pieces of new technology that provide better results——hence the Nova Scotian PM going to the US and NOT India for his stents
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.