31st December – Editorials/Opinions Analyses

Contents

1. HEALTHCARE IN INDIA: HEALING WITH A PERSONAL TOUCH
2. OUTLOOK FOR THE INDO-US TIE IN 2020

HEALTHCARE IN INDIA: HEALING WITH A PERSONAL TOUCH

Timeline of development of healthcare in the United States since the early 20th century.

• Mayo brothers’ initially modest set­up (Mayo Clinic) prolifically expanded into the prototypical ‘multispecialty group practice’ in the U.S.
• Concerns that such arrangements would be bereft of the personal touch in patient care were raised.
• The concern continued with the evolution of more and more organized structures like Health Maintenance Organisations (HMOs)
• Criticised for turning healthcare into a marketable commodity sold by unfeeling healthcare providers in supermarket ­like institutions, destitute of traits like empathy, regard and loyalty.
•  U.S. healthcare has ended up as one of the most impersonal healthcare systems.

Problematic proposition

• The NITI Aayog’s proposed 15­year plan for Indian healthcare entitled “Health Systems for a New India: Building Blocks — Potential Pathways  to Reform”
  • Outlines prospects of such an infelicitous turn in Indian healthcare.
  • Some commendable proposals for health system strengthening
  • Elimination of informality,
  • Merging of fragmented risk pools,
  • Reduction of out­ of­ pocket health spending

• However the proposal to consolidate small practices into larger business­like Organisations appears problematic on multiple fronts.
• Nearly 98% of healthcare providers have less than 10 employees is identified as a negative trait
• Apart from cost and competition related concerns, an enthusiastic pursuit of it could portend an exacerbated commodification of healthcare from the bottom ­up.
• The report’s bent towards the U.S. HMO model further adds to such a foreboding.
• Loyalty and longitudinality form vital pillars of the patient ­physician relationship. The edifice of these is built upon a substratum of mutual trust, warmth, and understanding that accrues over time between a patient and their personal physician.
• Momentary and haphazardly physician ­patient interactions in a system that limits access to one’s ‘physician of choice’ are incapable of fostering such enduring relationships.

Role of personal Physician

• A family physician’s longitudinal relationship with their patient helps in a better understanding of the patient’s needs and expectations and in avoiding unnecessary clinical hassles and encounters
• This in turn reflects in better outcomes and increased patient satisfaction.

Widespread commercialisation of care over the past few decades has entailed that the family physician is a dying breed in India today.

• This has a sizeable role in impairing the doctor ­patient relationship Increases violence against healthcare providers.
• Mistrust in the healthcare provider and its gruesome implications

Advantage of small clinics

• Healthcare received in small clinics scores higher in terms of patient satisfaction than that received in larger institutions.
• This increased satisfaction manifests as better compliance with the treatment regimen and regular follow­ ups, culminating in improved clinical outcomes.
• Patient­ clinician relationship has a statistically significant effect on healthcare outcomes. Indeed, disregard for this aspect in health services design is bound to entail a sizeable cost to the health system.
• However, the subtle, fuzzy, and perceived non­urgent nature of this problem keeps it from assuming significance to policy­ makers — as a result of which doctor­ patient relationship considerations are largely invisibles in the policy discourse in favor of more pressing concerns like lack of funds and manpower.
• Time and again, however, this omission has surfaced in the performance of health systems worldwide. As India looks forward to a long­ term healthcare plan, neglecting this consideration could be of sizeable consequence.

The need for empathy

• A popular myth often floated is that considerations regarding emotive aspects of healthcare such as empathy and trust are disparate from, and thus cannot be realistically factored into, hard­headed health policy and system design considerations.

• In reality, these are entirely amenable to cultivation through careful, evidence­ based manipulation of the health system design and its components.
• It would necessitate, among other measures, installing an inbuilt family physician ‘gatekeeper’ in the health services system who acts as the first port of call for every registered patient.
• The NITI Aayog’s long term plan provides a good opportunity to envisage such long ­called ­for reforms, but that would require not the U.S. model but the U.K. model to be kept at the forefront for emulation.
• Already taken a minor, yet encouraging, step of sorts by introducing Attitude, Ethics, and Communication (AETCOM) in the revised undergraduate medical curriculum.
• One hopes that the pronouncement of this long ­term healthcare plan doesn’t indicate adoption of U.S. ­like healthcare policies. The plan needs to be revisited to ensure that healthcare clinics delivering patient care don’t transform into veritable supermarket stores marketing medical services any further

OUTLOOK FOR THE INDO-US TIE IN 2020

Background

• The upswing highlighted by the signing of the civilian nuclear deal in 2008
• Started abating when Donald Trump became president of the US in 2017.
• Economic progress was the outstanding reason why India went up in America’s estimation after 1991.
• Its high growth rates over a 15-year period persuaded Washington to believe that it could become a counterpoise to rising authoritarian China.
• Additionally, India’s stability as a multicultural democracy also impressed the US, especially after the collapse of the authoritarian Soviet Union and Yugoslavia in 1991.
• By 2019, however, it was obvious to the world that India’s economy had fallen into decline over the last six years.
• Political and social polarisation, symbolised by increasing communal violence since 2014 and the large-scale protests over the Citizenship Amendment Act (CAA) have raised questions about the quality of its democracy.
• The economic downturn and New Delhi’s ruling out of a quick recovery brings into question India’s ability to counter China in Mr Trump’s “Indo-Pacific”.
• Over the last decade, India and the US have signed More than $15 billion worth of arms deals — and Washington recently offered India another $1 billion worth of naval guns.
• But to New Delhi’s chagrin, the US still refuses to transfer sensitive military technology because India is not a formal ally.
• Sovereignty decrees that India has a right to buy Russia’s S-400 missile, this air defense system blocks closer military ties with the US, which sees Russia as a security threat.
• Absence of an alliance reflects India’s determination to uphold its strategic autonomy, it simultaneously makes Washington doubtful about the viability of the Indo-US tie.
• Trade issues are another sticking point in their tie. India’s cat’s cradle of red tape and protectionist tariffs irk Washington.
• A mere 2.1 per cent of US exports come to India; and 2.2 per cent of imports come from India.
• Fifteen per cent of India’s imports come from the US, 16 per cent of its exports go to the US.
• As India’s economy has taken a nosedive, China has shown off its economic progress by expanding its Belt and Road Initiative (BRI) worldwide. Several member-states of the European Union and all of India’s neighbors have joined the BRI.
• China’s financial clout has established it as the largest investor in their economies.
• It is also the largest arms seller to Myanmar and Bangladesh. Its growing presence in the Indian Ocean poses tough queries about India’s standing as the dominant South Asian power.
• The other domestic development — the passing of the CAA and the large-scale protests that it provoked have led many in the US to question India’s secular democratic credentials.
• Even before that, the State Department in June reported that religious intolerance in India had grown under Prime Minister Narendra Modi’s government. India predictably riposted that a foreign government had “no right” to comment on the country’s internal affairs.