NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Editor’s Note: This is the second post in a four-part series on developments and challenges in Indian health care. Other posts include:

• Part 1: Zeena Johar discusses growth areas in Indian health care, and a potentially game-changing development that may be on the horizon
• Part 3: Johar’s tips for dealing with quacks, creating a market for primary care, and developing an effective business model
• Part 4: An overview of the biggest challenges facing Indian health care, and nine solutions for solving them

Zeena Johar is the president and founding member of IKP Centre for Technologies in Public Health, and CEO of SughaVazhvu Healthcare. In this second post in our series on Indian health care, she provides insights on addressing the provider shortage in India and reaching rural markets.

James Militzer: We’ve talked about the experiments the Indian government is doing with subsidized insurance for primary care. Are there other things the government could do to encourage more private enterprise there? For example, maybe by addressing the shortage of primary care providers in rural areas?

Zeena Johar: The government has been working in various shapes and forms to do that. For example, the government came up with a regulation saying that if you get your degree from any medical college, then you have to do compulsory internships in rural geographies. That has seen limited success.

But with the kind of scenario that you see in rural geographies, with dispersed populations and all of that, just producing a lot of doctors who will go there will not necessarily work.

What we really need to do is to look at innovative solutions. For example, in a partnership with the School of Nursing at the University of Pennsylvania, we are looking for ways to systematically transfer the nurse practitioner success that is there in the United States to the Indian subcontinent. So in our own ecosystem, we are training health care providers in the Indian system of medicine – like the ayurvedas and unanis. These are primarily the form of medicine that was practiced many, many years ago, but their training is very similar to conventional modern medicine training. What we have done is to very systematically identify gaps in the training in, say, pharmacology, physiology, case assessment and all of that. And along with the school of nursing, we’ve put together a bridge training program which helps us train these providers to provide basic primary care.

This frontline workforce is very suitable for rural geographies. The way they are trained, they are very well-equipped to understand and relate to the communities that they are serving – and they are very medically competent as well.

In India, you’ll hear a lot about community health worker programs. They are great when you want to really push for behavior change interventions, interventions that are truly lasting. But you cannot necessarily train a community health worker to be your front-end care provider. She cannot be trained to dispense medicine, or to diagnose, say, diabetes, and get the patient started on diabetic medication. So when you’re talking about creating integrated care networks [for rural Indians], you need competent providers who are happy to work in those geographies. You need people who are systematically trained to provide quality care, and mechanisms through which you audit them and hold them accountable for the outcomes of the care they provide. And you need to stitch them up into a larger network, whether that’s a secondary or tertiary network, or an insurance network – or whatever that means.

JM: How do you encourage highly trained providers to live and work in a rural area – aside from government mandates?

ZJ: These Indian medical providers that I’m talking about, most of them actually come from the communities where they’re expected to serve. A lot of Indian medical providers belong to these [rural] communities, and for them to be able to understand and integrate into these communities is not a very difficult proposition.

But there is a career path that is shown to them. It’s not like, OK, you go to this village and spend the rest of your life only in this village. It’s like, OK, this is a process through which there is skill enhancement in your career, and you can go from being a health provider today, to being a master trainer tomorrow. Then, if you are interested in going toward management of networks, you go to that space – or you continue your medical education to become more and more competent in your area of specialty.

JM: So if a private company wanted to set up a network of clinics in rural areas, you might advise them to try to recruit and train people from those areas as an early step in the process?

ZJ: Oh, absolutely, there is no other way. If you look at even the tertiary care setup, of course they don’t produce their own cardiologist in-house, because they don’t require 500 cardiologists. But if you look at their nurses or technicians – for example, Aravind Eye Care, which is known as a center of excellence in eye surgeries, with their ophthalmologists doing 100 times more eye surgeries than any ophthalmologist in the world. At Aravind, other than performing the incision and changing the lens, everything else is the job of a skilled worker that assists the physician. Hence, it is like a moving chain of surgeries that an ophthalmologist performs once he enters the operation theater. And the outcomes or infections are not any worse.

Now how did they manage to do that? They needed tons and tons of resources, so they went out and got local talent. And for every assistant and technician in the system, a very clearly defined protocol was written, and they were trained aggressively only on that one thing – whether it’s patient preparation, or assisting the physician through the surgery, or patient monitoring, or working in the labs where they actually make their own lenses in house. This has brought down the cost of cataract surgeries to 1/100th of what they were, and it has taken the excellence in surgery, in clinical outcomes, to a completely different level.

The success of the whole story is simple: how do they utilize the resources which are very much available locally? They don’t look for people who are post-graduates before they can come into the system. They bring in local people, train them on some very specific task, then make them perform those tasks in a very systemized setup.

(Above: Zeena Johar)

Within India, in any sphere of health, businesses that have done well and have scaled beyond the current supply of resources in the market end up actually developing their own schools, their own colleges, their own systematic methodology and their own lag time. They say, ’OK, if I anticipate this growth, I need to start training these resources two years, or one year, or six months in advance.’ Most of the successful examples in India have their own in-house breeding center, because there aren’t that many resources in the market when you need 100,000 of them.

JM: Considering all the demands of doing business in India, is there any space for smaller enterprises, or is it only for big players with the resources to, say, set up their own in-house training centers?

ZJ: Actually, within primary care, there is only space for smaller providers to come in – because you need a lot of innovation, improvisation and customization of solutions. So you need a person with the start-up mindset, or a small company which has that flexibility to change and innovate when you’re getting started.

But in primary health care, it’s not that there are no doctors available. To a reasonable scale, you can work with the talent which is available in the market. Only when you go beyond a certain mass, you begin to need to systematically think about in-house production – but not to get started. Later, when you want to open 700 health centers, absolutely there will have to be very serious thinking about how you produce that supply in bulk form. But that is not the first worry of health care entrepreneurs in any space.

JM: Are there any technological innovations that look promising for primary care providers in rural areas – like telemedicine?

ZJ: I’m not very sure about telemedicine, because I view the rural market as an opportunity for providing end-to-end solutions, and telemedicine limits you very quickly. You cannot dispense medicine, you can’t do too much blood work. So it has severe limitations.

A model which will do well eventually will definitely be a more systematic, fuller model. Technological innovations which are useful are the kinds you are seeing in India, for example, by the company BioSense, which has developed a technique to test hemoglobin without pricking you. That kind of device has great applications in rural environments, when you’re talking about making people much more aware of their health status. Another company called Embrace (See a NextBillion post on Embrace here) provides a very simple solution for maintaining body temperature in hypothermic infants that need to be transported to the nearest facility. So there is a lot of innovation focused on aiding front-end providers to arrive at much more appropriate diagnoses, and to deliver care much more efficaciously.

But we need technological solutions to be able to monitor providers who are working at the front end, whether it’s audit, or supply chain, or simple expiry of drugs – all of that. And the Indian market is very poorly evolved within the electronic record space, so that leg is completely missing. But that will come when the market is more evolved. We also need more innovations in front-end diagnostics, like simple ECG’s, simple ultrasounds to detect many more conditions – those are solutions we need as we put together a business model around primary health care in India.