President & Group Managing Director: Dr.Shelly Ahmed | Editor in Chief & CEO: M H Ahssan
Showing posts sorted by relevance for query health. Sort by date Show all posts
Showing posts sorted by relevance for query health. Sort by date Show all posts

Friday, March 13, 2015

Is Best Health Insurance An 'Expense' Or An 'Investment'?

SPONSORED: There are two schools of thought in India - one who believe in the concept of Health Insurance, are aware of the benefits and are pro-active about it. 

And the others, who feel that they are fit and can never fall ill, discard the need for health insurance; even though they are in agreement of the fact that the costs of hospitalisation and medical treatment have reached sky high in the last few years. So, to combat their queries, I thought of writing about Health Insurance in India, its penetration and importance and whether or not it should be mandatory, by law or by principle.

Sunday, May 30, 2010

WEEKEND SPECIAL: Mental Health: Lost In Translation

By M H Ahssan

Bhagwati Kumar, 58, has been suffering from depression since past three years. She is on medication but is reluctant to disclose her condition to others in her neighborhood, even though they perceive her as unfriendly. "The depression medications make me sleepy and I find it hard to keep my appointments," she admits. Also, she feels drowsy and tends to yawn during conversations, something that people find rude. "It was different back home with family around. Here I have few neighbors as friends and now even some of them don't talk to me. Even I don't feel like talking to anyone most days," she says. Bhagwati lives in Ontario with her son in a two-bedroom apartment and doesn't have much company throughout the day. "My son has his own life and work. After I complete the cooking I don't really have a lot to do," she reveals.

Unfortunately, Bhagwati is not alone in her misery. There are many South Asian immigrants who are fighting depression and other mental health problems silently. Many are not even aware that they can easily seek help and get better.

So recently, despite the temperature hovering around 14 degrees Celsius and chances of showers, 600 people, mostly South Asians, donned their running shoes to participate in the Lions 5K Walk on raising awareness about mental health in their community in Ontario.

"Mental illness costs the Canadian economy a staggering $51 billion a year in health care and lost productivity. Only one-third of those who need mental health services in Canada actually receive them," emphasizes Gobind Sharma, Co-Chair, Lions 5K Walk. The walk was organized by Milliken Mills Lions Club, a Markham-Ontario chapter of the international voluntary organization, Lions Club and Social Services Network, a not-for-profit agency.

The immigrant communities, especially from India and Pakistan, are one of the last to get help when it comes to mental health problems, including depression, schizophrenia, bipolar disorder, substance abuse disorder and obsessive compulsive disorder. And there is an urgent need to raise awareness about mental health issues, especially within the South Asian community that still tends to ignore them.

Together, the walkers circled boulevards near the brick and glass building of Markham Civic Centre and the city town hall of Markham, an Ontario suburb that has one of the highest concentrations of South Asians. "The $30,000 raised through the walk will be used to raise awareness about mental health," said Sharma.

The reasons for engaging South Asians in a walk on mental health are not hard to find. The town of Malton is a ready proof of the fact that South Asians in Canada shy away from getting help when it comes to mental health. Malton is a part of Mississauga, Canada's sixth largest and fastest growing city, and a showcase of multiculturalism constituting immigrants of different nationalities. Yet, in comparison, a homogenous Malton is a long-forgotten and best-ignored part of Mississauga. It is commonly referred to as Mississauga's "ugly little brother." It has a small population of 38,174 of which 52 per cent are South Asians and 16 per cent are black. Punjabi, Urdu, Gujarati and Hindi are some of the most common mother tongues spoken in the town after English.

In March 2009, various not-for-profit groups, government health agencies, and prominent mental health institutions came together at Malton to discuss some of existing lacunae in accessing mental health. Many grim realties were discussed at this meeting, including the fact that people who do not speak English are less likely to receive treatment for their mental health problems and more likely to have their mental health disorders go untreated. This is because when it comes to mental illness, immigrant communities lack information. They are confused about "what questions to ask, who to ask and what the services are." Also information on mental health issues is not available in the languages they speak.

Aside from language barriers, another reason cited by experts was that, even after migrating to Canada, people tend to hold on to the mindsets prevalent in their home countries. "There is stigma attached to mental health," agrees Dr Ravi Kakar, a consultant psychiatrist practicing in Scarborough, Ontario. He says that in his practice it is not uncommon to come across clients who avoid seeking medical help for as long as possible. "They will seek help when things begin to fall apart. For instance, wait until the very end when their marriage is at breaking point because of mental illness," he says. And before coming to a psychiatrist, people like to explore other options, including seeking those who advocate witchcraft or getting rid of the evil eye. "Or they keep on dealing with a mental health issue as a karma of sins done in the past life," elaborates Kakar.

Health care providers agree that they too have their own set of problems, which makes it hard to bring the relevant services to immigrant communities. Lack of data is the primary reason for the delay. This was what Kwsai Kafele, the Director of Corporate Diversity at the Center of Addiction and Mental Health, Canada's largest mental health and addiction teaching hospital, emphasized when he spoke at a workshop at Brampton Civic hospital recently. He pointed out that the health monitoring system does not keep statistics by race. This means that there is limited comprehensive data on how ethnic communities fare when it comes to mental health issues and illnesses.

As a result, people facing mental health issues are not under the radar of health care providers, even as experts agree that immigrant communities are among those most in need of accessing mental health services.

One big reason for this is the process of immigration itself. The "healthy immigrant effect" is a reality in Canada. Immigrants come with better health, which deteriorates as they try and adjust to their new surroundings. Here, health includes both their mental and physical health.

"Immigration is a stressful process. You uproot yourself and try and settle in a different culture. You have to find a new job, learn a new language and take on challenges. Many people have anxiety problems and require counselling for balanced mental health," said Kakar.

Some of these issues are not unique to South Asians. "Mental health is a big issue in the Caribbean community and there is a need to demystify it," said Kafele, speaking at the workshop "Building Awareness of the Caribbean Community's Health." He said he tried to get an article published in a local ethnic Caribbean newspapers on mental health but was not able to do so because of the "stigma." Like Kakar, he believes that immigrants have to deal with chronic stress problems that are exacerbated not only by the process of immigration but also the poverty and racism that often accompany it.

However, voices are now being raised within the communities to generate awareness about mental health issues. "Our walk got a tremendous response from politicians and support from mental health institutes and the public at large," said Sharma. He is hopeful that these "small steps" will result in creating greater awareness about mental health.

Sunday, May 23, 2010

Missing: A 'healthy' debate

By M H Ahssan

If public health systems are failing on account of certain causes, the solution should lie in fixing them. However, it appears instead that the state seems to be looking for an escape route from the problems of its own inefficiencies.

When I first heard of the recently launched Rashtriya Swasthya Bima Yojana (RSBY) - a health insurance scheme to provide cover to Below Poverty Line (BPL) families - my first reaction was to feel happy that there is such a scheme. RSBY is an idea that has its origins in the Ministry of Labour, and is designed as yet another way to provide social security to people below the poverty line. Under the scheme, BPL families (up to a total of 5 members per family), will get insurance cover of up to Rs.30,000 per person per year.

It is well recorded that in India, those people who are economically below the poverty line or are at the margins need just one prolonged illness or hospitalisation to be pushed to the verge of bankruptcy. But a little more thinking about RSBY and our health sector, made me ask some questions: Why do we need an insurance scheme for BPL families?

Is it because we do not have adequate government medical facilities or trained doctors that people can access? Or is it because many government-run health care centres simply do not run the way they are supposed to? Or, could it be that, people have so little faith in our public health facilities that they simply do not go there even though they might become bankrupt paying for private health care? Or is it because there is an explicit policy statement in which we have said that we must encourage private provision of health care, because we have come to the conclusion that government facilities are beyond redemption?

Our opinions on the role of RSBY will vary, depending on the answers and explanations to these and other similar questions. In any event, the scheme is symptomatic of a larger problem. The health ministry has failed to deliver essential health care services to the population through the government health care system, and to overcome this failure, a different ministry wants to provide insurance to a section of the population so that they can access private health care.

How fruitful will the Ministry of Labour's labours on this front be? That remains to be seen. But one thing is clear - for the first time, the government has signalled to a large percentage of the population (over 20 percent) that they should access health care offered by private providers and that the government would be willing to work with insurance companies to finance this arrangement. Already, around 85 million people are covered under schemes such as Employees State Insurance Corporation, Central Government Health Scheme, etc. That number is a relatively small fraction of the total population. With RSBY, the push towards privately provided care will receive a much bigger boost.

Vouchers for private education
There are parallels to this in other sectors, notably education. RSBY is like saying that all children of BPL families will get an education voucher that will pay school fees (up to a certain limit) for children who wish to go to private schools. Education vouchers allow children to choose the private school they wish to go to depending on their perception of quality of the school, and any other relevant factors. The government gives a voucher to the child which she can present in the private school as her fees. The school then exchanges that voucher with the government for cash.

The argument goes that the schools will have to be perceived as "good" if more children have to enrol. This fosters competition amongst schools, where non-performing schools will lose in enrolment and the "good" schools will increase. So there is fillip for private providers of education services, and there is direct competition between government and private providers of education.

People vote with their feet. The hollowing out of government schools in urban areas, and increasingly in semi-urban areas and rural areas is a good example of this. If people believe that private schools provide better education, then they will be willing to pay for them and attend them. In many urban areas, children who go to government schools often have little choice, for they belong to the poorest of families, and in several instances, their parents have had very little education.

It is interesting to note that while we, as a nation, seem to be less than receptive to education vouchers as a policy intervention but in stark contrast are embracing health insurance as an option. Arguing that education and health care are two different kinds of public services would be missing the forest for the trees. The broad questions in this comparison are still relevant.

Without debate
Interestingly enough, the 2004 General Election manifestos of the Congress and the BJP both explicitly state that they will start an insurance-based health security scheme if elected. The Common Minimum Programme makes a similar statement. It would seem logical that before making an important choice like this one, it would be necessary to evaluate various existing and possible new approaches to addressing the problem from the point of view of effectiveness and costs, and then make an informed policy choice.

Our health care sector is at a stage of evolution where we can still make better choices - how much private provision would we like vis-a-vis government provision of health care services? In simpler words, what percentage of people would we like to depend on government hospitals as compared to private hospitals for treatment? This is a question we ought to ask now, given the relatively small scale of organised private health care. If the government actively promotes private provision of health care now (through programmes such as RSBY), then in two or three decades from now, it would be too late to ask how much private healthcare should our country have.

This is by no means an ideological stance, supporting government efforts and criticising the private sector. Rather, it is about short-term benefits and losses, and the likely long term impact. This debate is about asking these important pragmatic questions early enough, so that the choices and their implications are fully understood.

In the short term, the BPL families who benefit from RSBY will greatly appreciate the programme, despite the scheme's imperfections and shortcomings. It does in fact make better health care more accessible for those who might otherwise have had to spend significant amounts of money despite being unable to afford it. In the short term, given that our demographics are slanted towards a younger population, the insurance premiums that the government will need to pay will also be relatively low. As our population ages, the cost of such payments to insurance companies will naturally increase.

Under these circumstances of massive structural changes sweeping the sector, it would be pertinent to examine the kind of debates taking place. There are two kinds of conversations that dominate the discourse. One set of people are deeply concerned about the implementation of various government health schemes such as the Janani Suraksha Yojana (that attempts to promote institutional deliveries), or such other important programmatic interventions that will have a direct bearing on health outcomes. There is another set of people who are talking about health financing, and what options exist to make the necessary finance available to the health sector - be it government funding, raising private resources, insurance mechanisms, etc.

The National Health Policy 2002, talks about a number of things, but falls short of articulating a national vision for the structure of our health care system 10 years from now.

The Report of the National Commission on Macroeconomics and Health submitted in 2005 has some very high quality papers. This Commission chaired jointly by the Health Minister and the Finance Minister identifies some important issues facing the health care sector. In a candid assessment of the health care sector in India, the report says: "The principal challenge for India is the building of a sustainable health system. Selective and fragmented strategies and lack of resources have made the health care system unaccountable, disconnected to public health goals, inadequately equipped to address people's growing expectations". The reasons for failure can be attributed to three broad factors: poor governance and the dysfunctional role of the State; lack of a strategic vision; and weak management."

It would seem that if the health sector is failing on account of these three causes, the solution should lie in fixing them. However, it appears instead that the state seems to be looking for an escape route from the problems of its own inefficiencies by conceding a bigger role for the private sector.

In discussing the role of the private sector in health care delivery, the report goes on to say: "... the trade-offs in terms of welfare implications however cannot be ignored. It will raise the overall cost of health care in the country and generate pressures for increased budgetary allocations for government hospitals to stay competitive."

And then the same report while discussing the 'way forward' goes on to recommend that in order to improve the quality of health care, the country should "Gradually shift the role of the State from being a provider to a purchaser of care."

This stance raises some elementary questions: what is the likely impact on equity, cost and quality of services as a result of this shift in the medium to long run? What are the projections of the costs 10-20 years down the line? How sensitive are these numbers to any changes in demographics, or a mid-course change in policy? These questions have not been discussed in depth in policy circles, let alone in public debates across the country.

If there is one question that we need to ask now, it is this: have we as a nation reflected on the policy choices that we are faced with now? If we are unable to answer this question with enough conviction, we may end up losing another generation to poor quality health care for the majority of the people in the country. Is that something that we can afford?

Monday, August 24, 2015

Access To Health: Nowhere Near To Being A Healthy Nation

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SPECIAL REPORT
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The out-of-pocket health expenditure by the poor is spiraling and the government spending on public health care is reducing. The existing public health programes and insurance schemes are failing; private health care sector is not properly regulated; INNLIVE finds the health of our nation worrisome.

Despite our efforts and best wishes, our modus vivendi, work atmosphere and environment often lead to situations where we have to consult medics and get treatment. The Country Cooperation Strategy brief of the World Health Organization (WHO) informs that India accounts for 21 percent of the world’s global burden of disease.

Thursday, March 12, 2015

Avoid 'These Mistakes' While Buying A 'Best Health Plan'

SPONSORED: Health insurance has been getting a lot of attention lately. The sales of health policies are rising not only in the metro cities where the awareness levels are relatively higher but also in smaller towns and rural areas. 

People in India have realized that the only way to fight the spiraling cost of health care and safeguard them against critical illness is by buying a comprehensive health insurance plan. 

Every day thousands of visitors search for health insurance plans on MyInsuranceClub but most of them have no idea on how to pick one for themselves or their family.

Wednesday, April 01, 2015

How Motherhood Is No Longer The “Frightful Experience It Used To Be” In The Villages Of Odisha State?

Binita Kanhara, 32, a tribal woman from Rajikakhol village in Chakapada block of Kandhamal district in Odisha was very happy the day she learnt that she was expecting her first child. 

Nine months later, when the day came, her mother-in-law decided that the delivery would take place at home. Unfortunately, the newborn child did not survive as it was weak and anaemic and needed medical care. The incident left Binita traumatised for months on end.

Sunday, February 10, 2013

The Doctor Only Knows Economics

This could be the UPA’s worst cut to its beloved aam admi. Healthcare has virtually been handed over to privateers. Govt seems to have abandoned healthcare to the private sector.

Diagnosing An Ailing Republic
  • 70 per cent of India still lives in the villages, where only two per cent of qualified allopathic doctors are available
  • Due to lack of access to medical care, rural India relies on homoeopathy, Ayurveda, nature cure, and village doctors
  • While the world trend is to move towards public health systems, India is moving in the opposite direction: 80 per cent of healthcare is now in private sector
  • India faces a shortage of 65 lakh allied health workers. This is apart from the nurse-doctor shortage.
  • According to World Health Statistics,  2011, the density of doctors in India is 6 for a population of 10,000, while that of nurses and midwives is 13 per 10,000
  • India has a doctor: population ratio of 0.5: 1000 in comparison to 0.3 in Thailand, 0.4 in Sri Lanka, 1.6 in China, 5.4 in the UK, and 5.5 in the United States of America
  • Fifty-six per cent of all newborn deaths occur in five states: UP, Rajasthan, Orissa, MP and Andhra Pradesh
  • Forty-nine per cent of pregnant women still do not have three ante-natal visits to a doctor during pregnancy
  • An estimated 60,000 to 100,000 child deaths occur annually due to measles, a treatable disease
  • Uttar Pradesh, the most populated state in the country, does not have a single speciality hospital for cancer
  • The top three causes of death in India are malaria, tuberculosis and diarrhea, all treatable
  • The WHO ranked India’s public healthcare system 112th on a roster of 190 countries
  • Post-independence India’s most noteworthy achievement in the public health arena has been the eradication of polio and smallpox
  • Affair of the states
  • Best Public Health Kerala, Tamil Nadu,  Maharashtra, West Bengal
  • Worst Public Health Rajasthan, Bihar, Uttar Pradesh, Madhya Pradesh, Orissa

India is taking firm steps to a certain health disaster. All of 80 per cent of healthcare is now privatised and caters to a minuscule, privileged section. The metros are better off: they have at least a few excellent public health facilities,  crowded though they might be. Tier II and III towns mostly have no public healthcare to speak of. As the government sector retreats, the private booms. In villages, if you are poor and sick, no one really cares, even if the government pretends to. 

You go to the untrained village “doctor”; you pray, you get better perhaps; all too often, you die of something curable. “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist,” Amartya Sen said recently in Calcutta. “It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”

Sadly, even the few initiatives the Indian state takes are badly implemented. Hear the story of Suresh, 45, who lost his younger sister to cancer, eight months ago. He’s a guard at the guesthouse of a pharmaceutical company in Mumbai and could not afford her treatment, so he sold some ancestral farmland in Gujarat. That money covered but a few months of bills from a private hospital. He then turned to a government hospital, but it didn’t have cancer care. It didn’t help in any way for Suresh that he worked for a pharmaceutical company: his job didn’t come with medical benefits. “We brought her back home, hoping that if we saved on the hospital bills, we would be able to buy her medication. Finally, the money I had was too little to provide her basic help. Maybe if I had been able to buy her medicines, she would have been alive today.”

But the state could have ensured that Suresh’s sister lived had he been able to utilise the ambitious health insurance scheme announced in Maharashtra in 1997. The Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) is on paper supposed to provide for 972 surgeries, therapies or procedures, along with 121 follow-up packages in 30 specialised categories. It provides each family coverage of up to Rs 1.5 lakh in hospitalisation charges at empanelled hospitals. It even allows for treatment at private hospitals. But poor implementation has ensured Suresh and hundreds of families like his do not know of such a scheme. This is true of other schemes across the country too.

Meanwhile, health statistics are terrifying. More than 40,000 people die every year of mosquito-borne diseases, which are easily preventable; a maternity death takes place every 10 minutes; every year, 1.8 million children (below 5 years of age) die of preventable diseases. “We are the only country in the world with such a huge percentage of privatised healthcare. Recent estimates suggest that approximately 39 million people are being pushed into poverty because of high out-of-pocket expenses on healthcare. In 1993-94, the figure was 26 million people,” says Dr Shakhtivel Selvaraj, a health economist.

So the state’s pretence of reaching out to the poor is really quite a farce. Consider what’s been happening between the Planning Commission and health ministry. In November, the battle between then health minister Ghulam Nabi Azad and the Planning Commission came to light: Azad had pressed for increased spending on the public sector while the commission was intent on increasing private participation. This was a telling comment on the priorities of the UPA government. But with the 2014 elections in view, the government would like to present “health reforms” as a political tool. A framework for “universal health for all” is expected by April this year.

According to the draft of the 12th Plan, the government will increase spending on health from 1.2 per cent of the GDP to 1.9 per cent, with greater emphasis on public-private partnership. While the expert group asked for scaling up public funding from the current 1.2 per cent of GDP to roughly 2.5 per cent by the 12th Plan-end (2017-18) and to roughly 3 per cent by the 13th Plan-end (2023-24), the government only relented a bit—enough to give it room to announce more populous aam admi schemes. D. Raja of the CPI believes that “through PPP (public-private-partnership), floated in the 12th Plan, the government is working as facilitator for private sector”, something that goes against the constitutional mandate of a welfare state. 

Former health secretary Sujata Rao says the state “cannot co-opt the private sector to provide healthcare for which government is paying money without framing stringent rules and norms.” More than 70 per cent of expenditure on health in the past five years has come from households. In its nine years in power, the UPA has overseen the shrinking of the public sector and the boom in the private. 

All the while, it has paid lip service to aam admi causes—even as it pushes people from the margins into the wilderness. In those five years, the well-to-do have obtained better healthcare than ever before. Both the Congress and the BJP have said in their party manifestos that they want to make India a “health tourism” destination. That has already happened. Would the UPA, champion of the aam admi’s interests, pat itself on the back for that? 

Meanwhile, most private facilities ignore a Supreme Court directive to reserve a certain percentage of their beds and treatment for the poor because they were given land at concessional rates.

Barely 100 km from the national capital, the Kosi Kalan district of Uttar Pradesh, near Mathura, presents a pathetic picture of community health care. Four months ago, the primary health centre, which caters to more than 50,000 patients with two trained nurses and two doctors, was upgraded into a community health centre with a new building. However, doctors haven’t been posted at the new centre. Says Rajkumar, a doctor at the primary health centre, “We got the new building about four months ago. We are waiting for administrative sanctions”.

It’s a familiar tale of rural India. But what is also significant is that in the post-liberalisation era, the government health sector has virtually vanished from Tier II and III urban centres. Subedar Gupta, 32-year-old commercial vehicle driver from Gurgaon, has discovered that the government sector is an empty shell. It’s the private sector that has fleeced him. His wife Chanda Devi has been complaining of severe bodyache, itching and weakness for the last five years and no one knows why. Gupta spent about Rs 30,000 last month at private hospitals. He is now broke. “They ask us for same tests—blood test, X-rays and ecg. She is continuously on medicines. They are sucking all the money out of us.”

Millions of Indians living in small towns go through the same agony--not knowing where to turn to in the absence of a good health system. Because of that, thousands travel to Delhi’s overburdened AIIMS and Safdarjung Hospital, which are staffed with excellent doctors. The rest just pay for a private system designed to extract the maximum from each patient. “Public health is a big question in small cities. They have government hospitals, which are not well-equipped—in terms of infrastructure or adequate numbers of doctors and other staff.  There is also a shortage of woman doctors,” says Dr Rajesh Shukla, a consultant who has evaluated icds programmes in rural areas and studied medical care in small towns.

A large number of swanky hospitals and clinics have come up in urban India. But that does not ensure good care. There is also the issue of all this being loaded in favour of a profit-seeking system. Take the Rashtriya Swastha Bima Yojna, a government-supported health insurance scheme that rides on the private sector to provide medical care and surgical procedures at predetermined rates. Experts point to the dangers of induced demand and the prescription of unnecessary procedures to claim insurance benefits. Besides, the technology at private centres is often used to fleece patients rather than help them.

Dr Subhash Salunke, former director-general of health services, Goa, and currently director of the Public Health Federation of India, says the private sector is very scattered and unregulated, leading to lot of malpractices. This could have been checked to some extent had rules of the Clinical Establishment Act, 2010, been framed and implemented. Two years after the legislation was passed by Parliament, it hasn’t been implemented. The problem lies with the “stiff resistance from the private sector to the laying down of guidelines”.

The health sector is also crippled by a shortage of doctors and nurses (see graphic). So when the government says it is serious about training more doctors and nurses, by setting up six new AIIMSes, it makes for sound planning. But politics quickly shows up: one of the AIIMSes is planned in Sonia Gandhi’s constituency, Rae Bareli. Many doctors trained in excellent government medical colleges swiftly move to the private sector; they are even reluctant to take up rural jobs or postings. 

“Of the 1,400 doctors appointed after a proper selection process, only 900 joined the service,” disclosed a spokesman of the Uttar Pradesh health directorate. Because of the shortage of doctors in government hospitals, the National Rural Health Mission (NRHM) had started to recruit those trained in the Ayurvedic, Unani, Siddha and homoeopathic streams, but the process was stalled by a Rs 5,000 crore scam.

So the poor continue to suffer. In a general ward of Krishnanagar Hospital in Nandia District, West Bengal, members of a patient’s family say that not a single doctor checked their ward for 24 hours after he was admitted with a cerebral condition. The doctor assigned to the hospital, who was in his chambers some 10 km away, had this to say when tracked down by Outlook, “I’m the only doctor for close to 500 patients. Is it possible for me to visit each and every patient? You have to understand my constraints. There is very little monetary incentive for doctors working in the rural areas. These are punishment postings. No one wants to come here. They want to work with rich patients and earn big money.”

As he spoke, there were close to 100 patients waiting in the visiting room to see him. They were all from the villages and small towns in Nandia district. Krishnanagar Hospital is the main district hospital and patients from all over Nadia are referred to this hospital. In Uttar Pradesh, modern private health services have yet to reach beyond a dozen key cities. The rest of the state has to depend on these 12 cities, a handful of which have facilities for tertiary care. 

Some facilities are available only in Lucknow, where the government has concentrated all the healthcare while the rest of the sprawling state—75 districts—goes without even secondary care. According to the NRHM’s fourth common review mission report, of the 515 community health centres in Uttar Pradesh, 308 were below norms laid down in the Indian Public Health Standards.

Even in states that are economically better off, such as Andhra Pradesh, it is an abject tale. Right from Seetampeta in north Srikakulam district to Utnoor in Adilabad, the public healthcare system is in a shambles. Adivasis simply have no access to potable drinking water and succumb easily to totally preventable diseases. If it’s gastroenteritis in Adilabad, it’s malaria in Paderu Agency of Visakhapatnam district. 

Anti-larval spraying operations are late and haphazard. Community health workers are badly trained. Human rights teams which visit these areas say the medicines provided are sometimes past the expiry date. “Deaths due to malaria are sought to be passed off as due to other diseases like cancer, heart stroke, old age or TB,” says V.S. Krishna of the Human Rights Foundation. 

Once touted as a model state for implementation of health insurance, Andhra Pradesh today faces a problem where the scheme is being misused by the rich. A qualified doctor himself, the late YSR, former chief minister of Andhra Pradesh, launched the Rajiv Aarogyasri Scheme in 2006, providing medical cover of up to Rs 2 lakh for bpl families. Since corporate hospitals handle a bulk of the procedures, the scheme is misused. Says a cardiac surgeon at a leading Hyderabad hospital, “The rich come and seek heart procedures under Aarogyasri, casually whipping out white cards meant for bpl families. There are no checks.”

The ailments of the poor often have nothing to do with the agendas of rich and powerful pharma companies. Are there lessons India can learn from the world? Experts say that the US has one of the worst public healthcare systems in the developed world. But in most countries, in Latin America or Europe, universal healthcare been achieved through governments. 

In Asia, Sri Lanka and Thailand can teach India some lessons on the health front. So India may be a powerful nation simply by dint of its size and market. But it is also a ‘sick’ nation, where there’s no help for the poor when they fall sick. It’s a country where a poor man can die on the pavement outside a gleaming state-of-the-art hospital with the best medical technology in the world.

Saturday, April 14, 2012

Can Telemedicine Alleviate India's Health Care Problems?

Chakrajmal village, in the Bijnor district in the North Indian state of Uttar Pradesh, got its first doctor in 2008. He was not based in the village, though. The villagers had access to the doctor via a telemedicine project launched by World Health Partners (WHP) to provide health care services to 1,000 villages in Uttar Pradesh's Bijnor, Meerut and Muzaffarnagar districts.

Set up in 2008, WHP, a U.S.-headquartered international nonprofit, provides basic health care and reproductive health services by harnessing local market forces to work for the poor. According to Gopi Gopalakrishnan, founder-president of WHP, the organization's model is to draw on private sector capacity through social franchising, innovations in labor management, and low-cost technologies to develop a scalable and sustainable health care service delivery model.

WHP's Uttar Pradesh telemedicine network now comprises around 1,200 local individuals called Sky Care Providers and 120 entrepreneur-run centers branded as Sky Health Centers. The Sky Care Providers are given training and low-cost mobile solutions by WHP to perform diagnostics, symptom based treatments, tele-consultations and, wherever needed, referrals to the Sky Health Centers.
These centers use remote diagnostic devices for measurement of basic parameters such as blood pressure, heart rate, electrical activity of the heart and pulse rate. The patients are connected to doctors at WHP's central medical facility in New Delhi via computers and webcams. The entrepreneurs have the option of leasing the equipment from WHP. For the patients, consultation charges vary from 20 U.S. cents for below poverty line households to US$1 (at the exchange rate of Rs. 50 to a U.S. dollar).

Patients who require surgery, inpatient care or specialized procedures that cannot be delivered via telemedicine are referred to the nearest WHP franchised health care clinic. Currently WHP has 16 such clinics in Uttar Pradesh. Since 2008, WHP has provided villagers in Uttar Pradesh with around 35,000 tele-consultations for common ailments such as fever, indigestion and gynecological problems.

Gopalakrishnan is now replicating this model in Bihar. Currently there are 104 telemedicine centers up and running in 13 districts of the state. He hopes to expand to 400 centers across 25 districts (covering a population of 70 million) by end of 2012 and 1,250 centers over the next three years. Apart from treating basic ailments, Gopalakrishnan now also wants to focus on detection and treatment of tuberculosis, visceral leishmaniasis, childhood pneumonia and diarrhea.

"There's a huge, unmet health care need in our rural hinterlands. The challenge is to make health care affordable for the masses and attractive to the providers at the same time," says Gopalakrishnan. "Telemedicine is a good strategy to strengthen the existing human resources available in health care. The scale, however, will come only through effective government intervention."

According to Rana Mehta, executive director and leader of health care practiceat PricewaterhouseCoopers (PwC), access to health care in India "gets limited by the affordability factor and hence telemedicine -- or the remote diagnosis, monitoring and treatment of patients via videoconferencing or the Internet -- has a very important role to play. It is at a fairly nascent stage right now having started only about a decade back, but it is undoubtedly a fast-emerging trend, led by growth in the country's information and communications technology sector."

K. Ganapathy, president of the Apollo Telemedicine Networking Foundation, past president of the Telemedicine Society of India and adjunct professor at the Indian Institute of Technology, Chennai, is categorical that telemedicine is the way ahead. "We can't go far with conventional brick-and-mortal hospitals,' he says.

Vijay Govindarajan, professor of international business at the Tuck School of Business at Dartmouth College, not only sees India as one of the early adopters of telemedicine, he also notes that the country has the potential to develop innovations that can be adopted in other parts of the world, including developed nations like the U.S. "In the United States, we are thinking of IT [information technology] as just electronic medical records," Govindarajan says. "This shortchanges IT's full potential. Driven by extreme need, India is inventing new ways to use information technology to improve health care."

Govindarajan lists the reasons why telemedicine will take off first in India: A severe shortage of doctors, especially in rural areas; very high patient volumes; widespread availability of mobile networks; rapid growth in the availability of low-power, hand-held medical monitoring devices, and the shift away from the proprietary, local area network-based medical image archiving and communications systems to a networked tele-enabled system. "Innovations in telemedicine will accelerate in India, where access and cost are critical issues. These telemedicine innovations will be adopted in the U.S., where cost and access are becoming increasingly talked about. This is a classic reverse innovation story," he adds.

Potential for Growth
A January 2012 report titled, "Global Telemedicine Market Analysis," by RNCOS Industry Research Solutions, an India-based market research and information analysis company, projects that the global telemedicine market will grow at a compound annual growth rate (CAGR) of around 19% from 2010 to 2015. An earlier report in 2009, titled "Global Telemedicine Market: 2008-2012" published by Infiniti Research, a London-based market intelligence firm, pegged the size of the global telemedicine market in 2008 at US$9 billion. According to this report, Asia is the fastest growing region for the telemedicine market with India and China leading the growth.

There are no clear numbers, though, on the current size of the telemedicine market in India. Murali Rao, associate vice president for health care at the New Delhi–based research and consultancy firm Technopak Advisors, estimates the current size of the Indian telemedicine market to be around US$7.5 million. "This is expected to grow at a [compound annual growth rate] of 20% over the next five years," he says. That would take it to around US$18.7 million by 2017. Mehta of PwC on the other hand notes: "Studies indicate that the size of India's telemedicine market is expected to be US$500 million by 2015." (This is a nascent area and estimates vary widely.)

Ganapathy of Apollo points out that 80% of India's population has no direct, physical access to specialist health care and gives some back-of-the-envelope calculations: "Estimates suggest that the telemedicine market is at least for 800 million Indians. Even if half of these 800 million need to consult a specialist once a year, [that still amounts to] 400 million specialist consultations per year. Even if 10% of these are enabled through telemedicine we are talking about 40 million consultations per year from rural India alone…. The market potential for telemedicine is obviously enormous."

While the numbers may vary, what is undisputed is the potential that telemedicine holds. A major driver of telemedicine in India is the dismal state of health care in the country. India's government spending on health as a proportion of the GDP – currently at around 1% of the GDP - is among the lowest in the world. Even in other Asian countries, it is higher. The corresponding amount is 1.8% in Sri Lanka, 2.3% in China and 3.3% in Thailand. Despite the launch of the National Rural Health Mission in 2005, India continues to grapple with a 33% shortage of rural hospitals, which are called Community Health Centers (CHCs). Even in the ones present, there is an acute shortage of staff. According to the Ministry of Health and Family Welfare, there is a shortage of 50-70% of physicians, specialists, lab technicians and radiographers at the CHCs. And around 10-15% of them lack even basic amenities such as water supply and electricity.

Experts have time and again suggested that if the vision of "Health for All" is to be achieved by 2020, India will have to pump in 6% of its GDP in the health care sector. At the same time, technology-enabled health care networks can play a huge role by bridging the distance between doctors and patients through Internet and other telecommunication technologies.

Ground Realities
Some of the major players in telemedicine in India at present include Narayana Hrudayalaya, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute and Aravind Eye Care. Devi Prasad Shetty, a leading cardiac surgeon based in Bangalore and founder of Narayana Hrudayalaya Hospitals, predicts that it is only a matter of time before we see a huge spurt in the use of telemedicine. "In the early days, satellite was the only means of managing the telemedicine program and keeping satellite connectivity was not very easy," he notes."However, now with Skype and other ways of videoconferencing there are many options available. With the stabilizing of technology platforms, technical problems are extremely rare."

Shetty is at the helm of one of India's earliest and largest telemedicine programs. Launched around 10 years ago, the initiative is managed through satellite connectivity provided free of cost by the Indian Space Research Organization (ISRO). Presently, the Narayana Hrudayalaya telemedicine network is connected with about 100 telemedicine centers across India. Outside India, as part of the PAN African satellite network, it is connected to 55 cities in Africa. The connectivity also extends to some other places like Iraq, Malaysia and Mauritius. Since its launch, it has conducted around 53,000 tele-consultations in the areas of cardiology, neurology, urology and cancer. Narayana Hrudayalaya also has an electrocardiogram (ECG) network wherein general practitioners in remote locations are given a trans-telephonic ECG machine that helps transmit ECGs. Narayana Hrudayalaya gets about 200-300 ECGs daily. These are interpreted by its doctors and then communicated to the local doctors at the remote locations.

Shetty points out that telemedicine is not just about connecting remote locations. Six years ago, when Narayana Hrudayalaya started performing liver transplants on babies, its cardiac anesthetists did not have adequate experience for this procedure. So Shetty turned to telemedicine. Narayana Hrudayalaya's operating room in Bangalore was connected to the Children's Hospital of Philadelphia and the anesthetists there. "After hand-holding for about five to seven liver transplants, our anesthetists acquired the knowledge," says Shetty. He goes on to add: "In the coming years, most of the medical treatment will be through telemedicine either in the same city or in other countries. There will be enough gadgets available at home to check blood pressure, blood sugar, ECG, oxygen saturation, even ultrasound. Patients will consult the doctors through mobile phones or videoconference through cellphones."

Some of this is already happening. Recently, leading telecom player Airtel tied-up with Healthfore (a division of Religare Technologies) and Fortis Healthcare (a Religare group company) as the knowledge partner to offer Mediphone services to its customers. This service allows subscribers to access basic medical guidance on non-emergency health problems over the phone. The service is available around-the-clock at less than US$1 for each consultation.

Other telecom players like Aircel and Idea have launched similar services in collaboration with HealthNet Global, a Hyderabad-based emergency and health care management services firm. The subscribers who call to seek health advice are visited by paramedics who come with a laptop and medical diagnostic equipment and conduct consultations via video conferencing. This is also gaining traction among insurance companies. "We have already conducted 1,000 sessions since our launch in September 2011. We are currently present in Chennai, Mumbai, Delhi and Hyderabad. We plan to expand our services to all the metros," notes Rahul Thapan, global head of marketing & sales for HealthNet Global.

In December of last year, microfinance firm Equitas also launched tele-health care delivery centers in association with HealthNet Global. The project is funded by Fem Sustainable Social Solutions (FemS3), a nonprofit company operating in the social business space. Equitas' Consult 4 Health and Call 4 Health products, developed exclusively for the firm by the Centre for Insurance and Risk Management at the Chennai-based Institute for Financial Management and Research, allow its members to consult physicians from Apollo Hospital over video for a charge of US$1 a consultation. The patient's data is also stored for any further diagnosis and treatment in the future. 

"It is our endeavor to improve the quality of lives of our members and their families," says P.N. Vasudevan, managing director of Equitas. "Health care is a source of significant financial stress for this segment. The initiative with HealthNet Global using physicians from Apollo Hospital will bring a revolution by providing health care to the doorstep of our members and the best medical care anytime, anywhere. We will roll out our services from Chennai and gradually go pan-India." Currently, Equitas has three tele-health care centers operational in Chennai.

Other new models are also emerging. Take Mumbai-based MeraDoctor (My Doctor) founded in 2010 by Gautam Ivatury, who was earlier working in the area of mobile phone-based services, and Ajay Nair, a medical doctor with a master's degree in public health management from Harvard. A phone-based medical advice service, MeraDoctor works on a membership model. The company offers family membership plans for three months and six months; during this period, members are entitled to unlimited phone consultations with MeraDoctor's team of doctors. Members can also avail of discounts at select diagnostic centers that MeraDoctor has tied up with.
There are new products, too. Dartmouth's Govindarajan points to General Electric's innovative low-cost ECG machines, which were developed in India and can take digital images that can be emailed to cardiologists in the U.S. "[This gives] poor patients in remote rural areas access to world-class care," he says.

Another example is 3nethra from Bangalore-based Forus Health. Developed with the aim of enabling mass pre-screening outside the hospital environment, 3nethra is a portable, non-invasive device that helps in early detection of eye diseases like cataract, diabetic retina, glaucoma and cornea related issues. The digital information taken by 3nethra can be easily transmitted electronically. The device won the Samsung Innovation Quotient award in 2011. "At 3nethra, we wanted to work with the system and its limitations," notes K. Chandrasekhar, founder and CEO of Forus Health. "Even a minimally trained technician can operate it. The idea was to develop a solution that was cost effective. The device that we have developed is available for one-sixth the cost of present diagnostic devices. Also, it uses only 10 watts of power. It can run for four hours on a UPS, making it ideal for rural areas [which face enormous shortage of power]."

Challenges Remain
But even as the telemedicine scenario in India is seeing significant developments, challenges still remain. According to Narayana Hrudayalaya's Shetty: "The greatest challenge is getting enough medical specialists to see patients in remote locations and also to get the patients to trust the opinion by the doctors, virtually."

Healthnet Global's Thapan points out that India will soon have a billion phone connections and the network will not be a problem. "It's now about finding the right linkages," he says. Thapan notes that ASHA (Accredited Social Health Activists) workers, for instance, can be trained to aid the doctors. "It will help spread the network," he adds.

Apollo's Ganapathy suggests that the potential of telemedicine in India is still under-realized because of lack of awareness among the masses and lack of a business model that caters to all the stakeholders. "Telemedicine will never reach the critical mass for take-off until doctors are excited about it and unless people clamor for it as a cost-effective method. We need public-private-partnerships to drive telemedicine [in India]."

Mehta of PwC says the entire ecosystem needs to be strengthened. "Ten years ago, there was the technological barrier," he notes. "That has gone away. However, the economic barrier stays. The ecosystem, in terms of incentives for the hospitals, the broadband service providers and the patients, needs to be defined. That is the tipping point of the telemedicine market in India."

Saturday, February 22, 2014

Environment: Industrial Safety Thrown Norms To The Winds

By Sirajuddin Shaik | INNLIVE

In view of the violation of the norms for the health and safety of workers in thermal plants, the Supreme Court directs the High Courts to examine whether adequate health delivery systems are in place. 

The Supreme Court judgment in Occupational Health and Safety Association vs Union of India, delivered by Justice K.S. Radhakrishnan on January 31, has brought to the fore the serious health hazards faced by workers in coal-based thermal power plants across the country. 

A protracted legal struggle that began in 2005 has only culminated in the apex court giving directions to the High Courts to examine whether there are adequate and effective health delivery systems in place and to evaluate the occupational health status of workers in thermal power plants.

Saturday, March 14, 2015

Product Review: 'Health Companion' Plans By Max Bupa

SPONSORED: Let’s accept the fact that buying a health insurance policy isn’t on the priority list of many, and till 2013 I belonged to this cadre of visionaries. I woke up from this deep sleep quite recently when I was admitted in the ICU, and had to pay huge bills (almost 70 thousand for 7 days in ICU) before the discharge. This made me realise the importance of owning a health insurance policy, albeit in a much harsher way.

While finally picking up a health insurance policy I also realised that this task wasn’t easy, especially with a market full of options.

Tuesday, May 21, 2013

HEALTHCARE INDUSTRY CAPTAINS WARY OF NEWER BETS

By Soumya Parekh / Hyderabad

Delivering health care to a billion-plus population is very complex. And, like eating a Reese’s, there’s no right way to do it. In the past, Indian entrepreneurs have innovated on several business models that range from frugal to world-class luxury care. A testimony to its success is the fact that citizens spent Rs 1,650 billion, or 3.16 percent of the GDP (in 2011-12), on health care, whereas the government spent only 1.04 percent. In other words, a family of four spends nearly Rs 10,000 per year on health care. 

Saturday, March 14, 2015

Religare Care Health Insurance 'Criticare': How Good It Is?

SPONSORED: Specialized Health Insurance companies have brought tremendous innovation, and choice to the market. In fact, this morning I was thinking how the choice and convenience would have been if we did not have these players, and only depended on the “general” General Insurance companies.

Now, the fourth specialized health insurance company in India, Religare Health Insurance recently launched its first product – “Care”, an indemnity benefit health insurance policy, with a series of benefits.

Wednesday, February 13, 2013

How UPA Is Pushing India Into A Public Health Disaster?

Recently when the government of India allowed compulsory licensing of two hugely overpriced cancer drugs, the jubilation was not confined to India alone. Along with their Indian counterparts, public health activists across the world hailed the decision.

That is the relevance of India and its scale for the healthcare of the poor in the world. In fact, the government hadn’t done anything extraordinary. In quiet and gingerly steps, it decided to break the patents of two life-saving drugs with abusive prices.

One of them, that costs about Rs. 2.8 lakhs is available at less than Rs 7,000 now. The other one is yet to be made in India, but when it is available, it shouldn’t cost more than 10% of its current price.

The points CIPLA’s Yusuf Hamied made in a farewell interview with Business Standard is hugely relevant here: India’s policies should be suitable for Indians and the country should have an automatic right to break patents in the case of a national emergency.

As an example, he refers to multi-drug resistant TB (MDR-TB) as a national emergency and the need to make generic versions of available MNC drugs against it. He says that an MNC was working on a drug to sell in India and CIPLA wanted to join hands, but the former was disinclined. According to him, this is an ideal situation for the government of India to issue compulsory license (break the patent) and let Indian companies make generic copies that would not cost more than a fraction of the the original drug.

That is, if the Indian government is interested in the health and welfare of its people.

MDR-TB is certainly an emergency. India has close to a third of the world’s TB population and about 100, 000 of them are untreatable because the disease they have is resistant to the available drugs now. The solution is new generation of drugs, which are branded and prohibitively expensive. Without these drugs, not only these patients will suffer and die, but they will also infect others who will also become untreatable. The cycle will fast-breed more people who are terminally ill.

MDR-TB is just one of the health emergencies in India. The truth is that the country’s entire public health system is in a state of emergency.

India, with more than a billion people, has the largest number of sick people in the world for any disease – both communicable and non-communicable -, but the central and state governments don’t even attempt to acknowledge more than 20 per cent of them. The majority is dumped and doomed!

End of last year, an outspoken Jairam Ramesh said exactly this, when he deplored that the country’s public health system had collapsed. He said even Bangladesh and Kenya were better than us and that medical cost was the biggest reason for indebtedness in rural areas.

He also said what public health activists have been saying for long – “India is a unique country” where 70 percent of the health expenses are bourn by the people themselves. Some say, it is not 70 percent, but 80.
But does his UPA government care?

Forget the ideal universal public health systems in countries such as the UK, France and Canada where the State takes care of its sick, even a terribly greed-driven America is changing its ways with Obamacare. Any sensible government knows that bad health of its people is a national security issue.

The AIDS epidemic in many sub Saharan African countries, where every socio-economic indicator including the GDP, drastically fell over a short period of time is a grim reminder that if your citizens are sick, the country is sick. Even MDR-TB had similar impact in countries such as Haiti. India has several health emergencies – ranging from killer communicable diseases to lifestyle illnesses – rolled into a single behemoth, but the government doesn’t care.

The reason is not resources, but politics. Health is the most neglected and politically low- profile ministry that no ambitious politician wants to touch. Some time back, a prominent Congress woman politician, reportedly sulked for long when she was made the health minister. Both the UPA and the NDA had assigned the ministry to low-weights and junior allies, whose prime occupation was to clear medical colleges and framing policies to help pharma industries and hospitals profiteer. It’s this neglect that resulted in a booming and rather unregulated private health sector, and the collapse of the public sector.

As an article in the latest issue of Outlook magazine, notes, the government seems to have abandoned healthcare to the private sector. The article quotes Amartya Sen: “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist…It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”

With examples from different parts of the country, the article establishes how our public health system has collapsed and how endangered are the lives of millions of poor people. It shows that even the vertical programmes funded by the Government of India and the state run programmes are poor and hugely inadequate. It’s absolutely justified to note that during the nine years of the UPA regime, public health sector has shrunk further and the private sector boomed.

The UPA government has to certainly own up this mess. It has been irresponsible to its people and doesn’t seem to be in no mood to change its policy. A High Level Expert Group (HLEG) of the Planning Commission had clearly suggested that India needed to move towards universalisation of healthcare and that it had to raise its health expenditure to 2.5 per cent during the 12th Plan period. The HLEG also said insurance was not the model that the country should adopt.

The HLEG report was a remarkable piece of policy advice, but the Planning Commission and the UPA were not interested. It committed less money, half-hearted attempts and also proposed more privatisation through the backdoor in the form of PPP. The CPI leader A Raja, quoted in the Outlook article is bang on when he says that “the government is working as a facilitator for the private sector.”

Such a pity that less than a year ago, Manmohan Singh committed to his countrymen that the 12th Plan would be a health and education plan. The PMO had said that if all went well, the health-spend of the government would triple during the plan period.

Look where he, his Planning Commission and government are now. Even countries such as Thailand, or even Philippines to some extent, know that the State can’t look away when its people are sick.
Indians are in deep trouble. They will have to spend more and more non-existent money for healthcare because the only option available to most of them (70-80%) is the private sector, which is a greedy and self-contained domain by itself.

What the mandarins of the Planning Commission and the UPA bigwigs do not understand is that ultimately bad health of our people will catch up with them as well. We have lost important people to diseases of the poor that scaled their high walls. Unless they build impossible green-houses at sea, they will not be safe.

What prevents the country, which doesn’t mind struggling over an impossible UID scheme, from implementing a cashless, universal healthcare system?

Monday, May 15, 2017

Violence in hospitals: Three steps towards mending doctor-patient relationships

Delhi’s mohalla clinics and Mumbai’s Swasth clinics have the right idea – make primary healthcare better.

Even after repeated protests, mass leaves and assurances from authorities of better security, incidents of violence against doctors continue unabated. Last week, a man whose critically ill father died at Sion Hospital manhandled a resident doctor, even though several security personnel had been deployed at the hospital since April.

Sunday, September 22, 2013

The Apathy Of Hospitals: One Doctor For 2,100 Indians

By M H Ahssan / INN Live

Last month, tragedy struck Bhargavi and Laisan Kanhar in Sambalpur district of Odisha. The tribal couple’s only child Banita who was in Class III fell into a hot egg curry cauldron at her school in Girischandrapur village while she waited for the midday meal.

The eight-year-old suffered severe burns and was rushed to the nearby primary health centre (PHC), where the only doctor was absent. The hospital staff applied first aid and referred her to the VSS Medical College and Hospital at Burla. 

However, there was no ambulance to take her to the hospital 72 km away. She finally reached there in a private vehicle nearly four hours after the accident. The same evening, she was again referred to the SCB Medical College and Hospital in Cuttack, nearly 300 km away. By next morning, Banita was declared dead at the hospital in Cuttack.

Thursday, October 13, 2011

Beyond Bureaucracy Challenge: How do Organizations Conquer Bureaucracy?

By M H Ahssan

To sustain high performance, organizations must build the capacity to learn and keep changing over time.

If you’re like most senior executives, you want your organization to be exemplary. But if you’re honest with yourself, you also know that it’s not and that, in fact, you’re not even sure what exemplary means or how you’ll ever get there. Most management writing won’t help: despite the multitude of volumes written on organizational excellence, nothing we’re aware of combines a view on the “steady state” of high, sustainable organizational performance with a dynamic perspective on how companies can transform themselves to achieve it.

We’ve tried to fill that gap with our forthcoming book, Beyond Performance: How Great Organizations Build Ultimate Competitive Advantage (Wiley, June 2011), from which this article is adapted. Our central message is that focusing on organizational health—the ability of your organization to align, execute, and renew itself faster than your competitors can—is just as important as focusing on the traditional drivers of business performance. Organizational health is about adapting to the present and shaping the future faster and better than the competition. Healthy organizations don’t merely learn to adjust themselves to their current context or to challenges that lie just ahead; they create a capacity to learn and keep changing over time. This, we believe, is where ultimate competitive advantage lies.

Getting and staying healthy involves tending to the people-oriented aspects of leading an organization, so it may sound “fluffy” to hard-nosed executives raised on managing by the numbers. But make no mistake: cultivating health is hard work. And it shouldn’t be confused with other people-related management concepts, such as employee satisfaction or employee engagement.

Nor should you study what other companies do and then apply their approach. While you can always learn helpful things from others, we have found that the recipe for excellence in a particular organization is specific to its history, external environment, and aspirations, as well as the passions and capabilities of its people. Creating and sustaining your own recipe—one uniquely suited to these factors—delivers results in a way that your competitors simply can’t copy.
Why health?
The case for health starts with an understanding of how it relates to performance. Performance is what an enterprise delivers to stakeholders in financial and operational terms. It is evaluated through such measures as net operating profit, return on capital employed, total returns to shareholders, net operating costs, and stock turns. Health is the ability of an organization to align, execute, and renew itself faster than the competition to sustain exceptional performance over time. It comprises core organizational skills and capabilities, such as leadership, coordination, or external orientation, that traditional metrics don’t capture.

More than a decade of research and even more of experience have led us to believe strongly that health propels performance—and that, in fact, at least 50 percent of any organization’s long-term success is driven by its health.
Statistical evidence
We have developed a survey to measure organizational health and administered it to over 600,000 employees at more than 500 organizations across the globe. The survey’s immediate purpose has been helping organizations to measure their health and then to improve in areas of weakness.

But the data we’ve collected over the years have also enabled us to study the relationship between organizational health and performance. And there’s a strong positive correlation. Companies in the top quartile of organizational health are 2.2 times more likely than lower-quartile companies to have an above-median EBITDA margin, 2.0 times more likely to have above-median growth in enterprise value to book value, and 1.5 times more likely to have above-median growth in net income to sales.

The results within individual organizations mirror the results from our large sample of companies. At a multinational oil corporation, for example, we analyzed correlations between performance and organizational health across 16 refineries. We found that health accounted for 54 percent of the variation in performance (Exhibit 2).

‘Experimental’ evidence
We’d be the first to admit that correlations should be treated with caution. But the case for health doesn’t rely solely on them. We’ve also tested our hypotheses at real organizations trying to improve the way they work.

At a large financial-services institution, for example, we selected an experimental and a control group that were comparable and representative of the wider organization by criteria such as net profit before taxes, customer economics, and branch staff characteristics. The two groups then implemented a sales stimulation program over an 18-month period—one using fairly traditional performance-focused methods, the other following a more balanced approach emphasizing performance and health.

The results were striking. In business banking, the traditional approach yielded improvements in value of 8 percent, the more balanced approach 19 percent. In retail banking, the traditional approach delivered a 7 percent improvement, compared with 12 percent for one emphasizing performance and health. Similar studies in other industries yielded similar results (Exhibit 3).

Evidence from transformation efforts
Finally, we’ve surveyed thousands of executives who have been through organizational-change programs. Data from one survey, on why change programs fail, showed that what we might see as “the usual suspects”—inadequate resources, poor planning, bad ideas, unforeseen external events—account for less than a third of the failures. More than 70 percent resulted from poor organizational health, manifested in symptoms such as negative employee attitudes and unproductive management behavior. Furthermore, our 2010 survey of executives at companies undergoing transformations revealed that organizations focusing on both performance and health rated themselves as nearly twice as successful as those focusing on health alone and nearly three times as successful as those focusing on performance alone.
Working toward ‘and’
The link between health and performance is good news. Unlike many of the key factors that influence performance—changes in customer behavior, competitors’ moves, government actions—your health is something you can control. It’s a bit like our personal lives. We may not be able to avoid being hit by a car speeding around a bend, but by eating properly and exercising regularly we are far more likely to live a longer, fuller life.

Of course, that doesn’t make the pursuit of performance and health any easier. Most companies know how to keep a close eye on performance, but health often suffers from neglect. We asked more than 2,000 executives to name the areas where they wished they had better information to help them design and lead transformation programs, for example. Only 16 percent chose near-term performance. More than 65 percent chose the company’s health for the longer term.

What’s more, even when companies do understand both performance and health, many pursue them separately. The result can be HR-led “people programs” that bear little relationship to a company’s strategic and operational imperatives, performance-improvement initiatives that cut more muscle than fat, or both.

In our experience, building health and achieving its accompanying performance benefits generally require transformational change. The approach we’ve found most effective for pursuing it consists of five stages, which we refer to as the five frames of performance and health. For each stage, you must answer a basic question that applies to both performance and health and then address a related performance- or health-specific imperative.

While no two change programs are alike, we believe that the five frames contain the key ingredients for an organization-wide transformation that delivers performance and health in almost all circumstances. In what follows, we offer examples from companies that have excelled in one stage or another to highlight what’s required to tackle both aspects of a transformation—with an emphasis on health, since pursuing it as an explicit goal is less familiar to most organizations. Although we firmly believe that each organization must find its own way through the five frames, these examples of companies that have made significant and lasting improvements in both performance and health offer some inspiration, as well as guidance on tactics we’ve seen work well.
Aspire
The importance of setting aspirations that emphasize health as well as performance came through loud and clear in one of our surveys: change programs with well-defined aspirations for both, we found, were 4.4 times more likely to be rated extremely successful than those with clear aspirations for performance alone.

Wells Fargo offers an example of how to pursue both: setting strategic objectives and then defining related health essentials. When current CEO John Stumpf became president, in August 2005, he brought his top team together in a two-day offsite session to debate Wells Fargo’s aspirations for its next era. The performance goal that emerged was to maintain the company’s track record of double-digit compound annual growth in earnings per share and revenue. To that end, the team doubled down on the bank’s long-term cross-sell aspiration of “going for gr-eight” (eight products per customer), with the medium-term goal of adding at least one product on average to its already industry-leading cross-sell rates. The bank’s leaders also set performance targets related to customer loyalty and customer attrition in all key businesses.

But a broader aspiration also emerged, which the team summed up in the phrase “One Wells Fargo.” This idea grew out of the realization that a huge amount of the value the team sought to create lay in what it called “mining the seams” of the organization: working together more effectively across the company’s lines of business to break down “silo thinking” and give customers a better experience that fulfilled more of their financial needs.

Thinking about the bank as One Wells Fargo helped the senior team focus on changes that would be needed to make the organization healthier: management practices related to customer focus, strategic clarity, and collaborating to share ideas and information were all strong within the lines of business but had to be distinctive across them as well. If One Wells Fargo was the strategy, organizational changes would be needed to support and enable it.
Assess
Before you move from goals to actions, it pays to take a hard look in the mirror to understand your company’s readiness to achieve its aspirations. What capabilities matter most to meeting your performance goals, and how strong are they in your company today? What mind-sets about “the way things get done around here” could undermine your quest for health, and what are their root causes? The value of such assessments of a company’s readiness to change can’t be overstated: in our 2010 survey, respondents at companies that diagnosed problematic mind-sets were four times more likely than those that didn’t to rate their transformations as successful.

When Pierre Beaudoin took over the aerospace division at Bombardier, in 2001, for example, he knew that it needed a performance boost to ride out the industry’s post-9/11 downturn. He also wanted the company to become a healthy, self-improving organization. The aspirations he set—Can$500 million in bottom-line savings, along with a continuous improvement in service and products for customers—required lean capabilities that Bombardier lacked at the time, as well as a significant change in mind-sets.

Probing cultural issues wasn’t something that came naturally to a company that prided itself on technical expertise. In Beaudoin’s words, “It was a challenge for me and for my leadership team to explain why we were spending so much time on the ‘soft stuff’ when we could be fixing factories, hardware, airplanes. We had lots of conversations explaining that if we did the soft stuff right, our employees, with our help, would be more able to do what they’re supposed to do, like make our factories efficient and work on engineering problems.”

These conversations and a more formal organizational self-assessment yielded a shortlist of beliefs that limited the value placed on individuals, the role of teamwork, efforts for continuous improvement, and the drive for results. One area where the company urgently needed to change was attitudes toward handling problems. As Beaudoin explains, “Suppose I come to a meeting and hear about four problems, and I slam my fists on the table and say, ‘I don’t want to hear about problems any more; you guys are there to fix them.’ Well, guess what—I’m not going to hear about problems. And that’s how you get yourself in deep trouble.”
Architect
Once a company knows where it wants to go and how ready it is to go there, it must work out the way from here to there. Countless leaders have told us that this is the hardest part of changing their organizations. But it’s also the stage in a company’s journey when efforts to improve performance and health start to fuse: they interlock and reinforce one another as a focused portfolio of performance-improvement priorities becomes a vehicle for shifting mind-sets toward health.

To understand what this symbiotic relationship looks like in practice, consider the turnaround A. G. Lafley famously engineered at Procter & Gamble after taking the helm, in June 2000. Lafley established some explicit priorities for P&G: focusing on 10 out of 100 countries, for example, and on four core businesses. Emphasizing these priorities was critical to P&G’s performance improvement. It also built a platform for one of Lafley’s deeper goals: to make P&G a more consumer-driven and externally focused company—a healthier one, in short.

As Lafley was setting priorities, he decided to draw up a not-to-do list. One item on it was P&G’s “skunk works”: experimental technology projects outside the company’s mainstream businesses. These endeavors—which had an annual budget as high as $200 million—reflected technological goals rather than customer needs and culminated in products and services that had to be “pushed” to the market in the hope they would be taken up. All this worked against Lafley’s customer-focused aspiration. And so the not-to-do list was rigorously enforced: “If we caught people doing stuff that we said we were not going to do, we would pull the budget and the people, and we’d get them refocused on what we said we were going to do.”

Often, shifting mind-sets means changing formal systems, structures, processes, and incentives. At P&G, Lafley made sure that planning processes started with an understanding of consumer trends and reframed the organizational structure to give it a stronger consumer orientation. Finally, role modeling, storytelling, and skill development can also play a vital role in shifting mind-sets. Lafley, for instance, set up an in-house college for managers and dedicated a substantial part of his own time to coaching. Although this soft stuff is often overlooked, it’s vital. Senior executives who told us, in one of our surveys, that they’d implemented initiatives to change their employees’ mind-sets and behavior during a transformation were twice as likely as others to report that it had succeeded.
Act
When it’s time to get moving, pilot programs are almost always the right way to start working on performance. If things go well, successes can be replicated elsewhere; if they go awry, you can confine mistakes to a small area. Early results also help to build your employees’ motivation and appetite for change. One key to successful pilots, we’ve found, is conducting them in two stages: first, a standard proof of concept and, second, a proof of feasibility, which will ensure that you have a replicable means of capturing the value you’ve identified across your organization. Too many companies don’t take the second step and find that they can’t build on their initial success.

But even the most carefully constructed pilots aren’t enough. Lasting, healthy change also requires an organization motivated to go the extra mile over and over again as employees carry out their routine, day-to-day tasks while fundamentally rethinking many of them. The whole process can feel like trying to change the wheels of a bike while you’re riding it. Not surprising, most companies find this difficult: one of our surveys found that only some 30 percent of all executives who had been through a transformation thought their companies had been completely or mostly successful at mobilizing energy in it.

CEO Julio Linares took the reins of Spain’s incumbent telecom operator, Telefónica de España, in January 2000, as earnings and cash flow were sliding. He used three methods to create a powerful engine for change as he transformed the company. The first was to help people “understand how the project they were working on would contribute to that year’s targets and, therefore, to the overall transformation program.” With that goal in mind, Linares and his team emphasized growth, competitiveness, and commitment as critical themes. Developing new distribution models and improving customer segmentation came under the heading of growth; adopting lean work processes and enabling online transactions, of competitiveness; and embedding a new set of company values and reorganizing business units, of commitment.

Second, Linares ensured that the whole company felt ownership of the changes. He and his senior team brought the telco’s top 500 executives together every January, for example, to help design the program for the year to come. Beyond this core group, Linares sought to “give relevant people at different levels of the organization an opportunity to participate” in the redesign of the transformation program “and then to complement that with a strong communication program.” Sometimes, companies need to reach out even further to create a shared sense of ownership. When structuring the transformation of India’s Larsen & Toubro, CEO A. M. Naik explained, “We involved one in four employees, about 7,000 people. I visited 38 locations of the company.” He added, “When the vision was finalized” in a document, “everyone could say, ‘That word was mine,’ you know? Maybe that word was in the minds of a thousand people. But the process created a shared vision everyone could believe in.”

Finally, Linares used progress evaluations, which are always important, as a third tactic for maintaining energy. Linares explained the need for them in this way: “The market is going to change constantly, and because of that you need to make a constant effort to adapt your company. Some parts of the program will end, but new ones will come up.”
Advance
The final stage is to make the transition from the intensive work and constant upheaval of a transformation to a period of continuous improvement. According to one survey, companies that build a capacity for it into their organizations are 2.6 times more likely to consider their transformation programs a success over the long term.

Continuous improvement can be cultivated during a major transformation effort by building an infrastructure, as you go, that includes knowledge sharing, learning methods, and expertise to help the company continue to improve. For these to be embraced after the initial transformation effort is complete, the right leadership skills and mind-sets must be in place. After the formal end of a transformation program at ANZ Bank, for example, the company trained more than 6,000 leaders in areas such as self-awareness, resilience, and the ability to energize oneself and others. The response was tremendous: participants spoke of the program’s “profound impact” and described the experience as “life changing.” ANZ also held other personal-leadership workshops to develop its employees’ ability to improve continuously, cascading the workshops right through the organization in a process that eventually touched more than 26,000 employees.

These efforts helped ANZ usher in an era of nonstop progress, which included grassroots business initiatives, organizational delayering, bureaucracy busting, internal job markets, and greater diversity. Supporting these endeavors were some 180 “champions” who worked, on top of their regular jobs, to foster continuous improvement in the businesses.

ANZ’s strong financial performance, in the years after its transformation, was accompanied by striking evidence of organizational health: it had the highest level of staff engagement of all peer organizations in Australia and New Zealand, and the share of employees who agreed that “we live our values” and “are earning the trust of the community” was 85 percent and 81 percent, respectively.

If you want to change your organization for the better and to make the changes stick, you must focus on its long-term health even as you push for higher performance now. We hope our research has convinced you that this sensible-sounding but often-ignored maxim is true. And we hope you see, from the examples earlier in this article, that practical insights and tried-and-true tools will let you tackle performance and health simultaneously. We fervently believe that business, and even society as a whole, will improve when organizations begin to report—and be judged—on their health just as frequently and rigorously as they are on their performance.