In thinking about healthcare systems – capability and capacity, a broad consensus in India is that the Indian state has failed in providing it. This diagnosis is broadly accepted. However, in thinking about responses to address the problems, it might be useful to not be completely led by experiences in the private sector – there is asymmetry of information ( ex-people have no clue if a prescribed medical procedure is indeed required) and there is an incentives problem (ex- few doctors want to serve in rural areas).
In a podcast Ajay Shah argues that the healthcare system in India is broken. The point on the necessity of data-driven diagnosis and management of healthcare process flows is well taken.
On philanthropy’s role he observes that there is a lot of ‘well meaning philanthropy in India where people try to do well and the answer is that let me go build a free hospital or let me go to underserved places like Bihar and run programs to do the nutrition interventions or vaccinations for kids and I’ll try to make the kids in Bihar healthier…’ Adding that ‘they do not solve the problem. The system is broken.’
Instead, he argues ‘it would be more effective to be cold and to be intellectual and to build knowledge, to build a research community because that’s where we will get deeper solutions and we will stop this thing for life. Otherwise, there is a boat that’s leaky and you’re just bailing.’
There is a gap in this line of thinking that philanthropies and independent, non-state initiatives do not solve the problem. The evidence seems to be the opposite of it. India has had several outstanding initiatives in healthcare and medicine that started small and as individual efforts in distant corners of the country and matured into outstanding tertiary care centers delivering tremendous value.
What suggests that through these initiatives one cannot understand the system or have clear, worked out solutions to fix it? The Bangs in Gadhchiroli (Research for whom), Drs Regi and Lalitha in Sittilingi, Dr V in Madurai, Binayak Sen and team at Jan Swasthya Sahyog in Ganiyari and many more professionals have carefully and deeply engaged with the problems over decades. They have also had demonstrable success in addressing public health issues of the marginalized and excluded. Their work has also made it to healthcare policy formulations of various governments.
Elsewhere in the same conversation Ajay is also clear about what he would like to do if he had a ‘horrendous situation’ at hand – I’d like to buy a ticket and go to Christian Medical College, Vellore. This is an old fashioned place where doctors are paid a fixed salary and there are no kickbacks. Okay? And in my opinion it is the best healthcare in India.
In that case, let us go back to one Dr Ida Scudder who in c1900 intended to start a medical school and a hospital for the sick and people in need around the villages of Vellore.
Her biographer Pauline Jaffery in a rather plainly titled biography ‘Ida S. Scudder of Vellore’ published in 1951 writes –
Throughout her long and arduous training as a medical student, Ida did not swerve from her accepted purpose. To return to India, qualified by skill and science to be of service to her people, was the one absorbing ambition of this eager and impetuous, yet disciplined woman. (…) Her busy brain seethed with great plans for the future.
The following sequence may be instructive in understanding how a small, let-me-go-build-a-free-hospital kind of urge grows into a fine tertiary care institution. The process is individual-led and it turns on passion primarily.
The little Guidyatham hospital did not spring up overnight. Beginning, as she often doesn, with the ‘near end’, Dr. IDa added a nurse’s cottage – quite a small affair – to the dispensary at the Church. A nurse was thus able to live in the town and treat the patients in the interval between the visits of Dr. Ida and they became so popular that a rope had to be use to fence off the waiting crowds. AMong these patients some would be too sick to stand the long motor journey to Vellore and, for a time, provision was made for in-patients in the Church itself during the week. A shed was then built and one vivid recollection is of the little Indian doctor, a graduate of Vellore, who was stationed at Gudiyatham in the nurse’s cottage.
She began with small beginnings. A foundation and two rooms were built with what money was available.
By c1920, Jeffrey notes that ‘In India, the Christian hospitals had trained about 80 percent of the nurses.’ In the Jubilee Year in 1950, Sir Samuel Ranganadhan, a former High Commissioner for India in England, who also served as the Council Chairman of CMC outlined the institution’s contribution –
At Schell eye hospital, 1,978 in-patients and 12,660 outpatients,
At Cole dispensary, an average of 120,000 out-patients yearly,
An X-ray plant for 7,588 diagnostic examinations in a year,
Three operation theatres for 2,251 operations in a year,
Two delivery rooms staging 1,417 deliveries in the Jubilee Year.
There are wards at Thotapalayam to provide 484 beds, and the twenty private ‘beds’ among these are so inadequate that more private wards are being erected.
In 2021, CMC Vellore has been one of the key research institutions driving epidemiology, vaccinology and pandemic response in India. Dr. Gagandeep Kang remains at the forefront. It is the same institution to which one would prefer to buy a ticket and fly down to because it is ‘the best healthcare in India’.
To summarize, I have used CMC Vellore’s institutional history to suggest that individuals and their cause matter to the system. It is not reasonable to disregard it. The larger point about the government (state) as the key regulator is of course pertinent to the national healthcare system but it cannot be the only provider of it. Even in a regulatory function it needs a community of practice that serves as the eyes and ears for the system. We have, by now, known the consequences of a clueless administrator who inherits the chair briefly, en route to a more coveted portfolio in other departments of the government. Philanthropies and faith-based institutions have contributed to the national healthcare capacity, research and future in a significant way. It is hard to ignore this fact. This should not be seen as ineffective or problematic.