India gained independence from Britain at approximately the same time as the United Kingdom (UK) National Health Service (NHS) was founded. Seventy years later, the quality of care in the NHS and in India inspire both pride and frustration.
India vs. the UK
An important difference between the UK and India is that the GDP per capita in the UK is over 40 000 USD—while in India, it is less than 2000 USD. For comparison, China's GDP is over 7500 USD. The number of physicians per 1000 people in the UK is double that in China, which in turn has twice as many physicians as India. The population of UK in 2014 was under 65 million; in China, it was 1.39 billion and India, 1.27 billion (Organisation for Economic Co-operation and Development (OECD), 2016).
In both China and India, respiratory infections are said to constitute the largest disease burden while, in the UK, this consists of cardiovascular and age-related conditions. This, of course, is not the full story. The economic growth figures for China and India are currently above 6%; whereas in the UK, it is less than 2%.
India officially eradicated polio in 2014, and many travellers no longer experience the infamous ‘Delhi Belly’ (i.e. traveller's diarrhoea). The current size of the health economy in India is measured in billions of dollars, and it seems to be an attractive destination for international health tourism despite adverse commentary from the UK and Australian professional journals (among others) about the standards of medical training and education (Clark, 2015).
International relations
As Britain progresses towards some kind of Brexit, and in recognition of its benevolent relationship with India, it is widely considered that a closer relationship between the international community and the Indian healthcare system is inevitable, desirable, and potentially in everyone's interest.
No one should pretend that the healthcare provision in any country is less than highly imperfect—but in India, substantial opportunities exist owing to the enormity of its present challenges. There is debate about how health care in India can and should adapt to the expectations of its population, and in response to ongoing investments from the public and private sectors (Dhawan, 2015).
Of course, there are distortions in the processes, such as a lack of symmetry and counter-intuitive behaviours in all countries. In India, these are often referred to as corruption—something that some economists call ‘rent-seeking behaviour’ or ‘leakages’—and represents a disincentive to engage at the ground level. However, no one familiar with substantially more affluent countries, including the UK and Japan, would deny that there are international versions of corruption which seem to defy simple solutions (Jain, 2014). If the international community wishes to contribute and benefit from its efforts in India, it needs to engage with sincerity for the long term—the example of Germany being a case in point (Dr Hempel Digital Health Network, 2017)—and be prepared to take the rough along with the smooth, as those working with countries in Europe, North America and elsewhere, do.
The Indian opportunity
The population of the Indian middle class is estimated to equal that of Europe, and its expectations and spending power exceeds that in several European countries (Kharas, 2011). Similarly, Indian society has European levels of diversity and complexity.
The best of Indian health care is as good as anywhere in the world. This is evidenced by the numerous outsourcing contracts between the NHS and Indian establishments; for example, for the provision of out-of-hours radiology and pathology services.
The tagline for the Indian tourism industry is ‘Incredible India’. Many people familiar with this country would prefer to call it ‘bewildering’ and/or ‘perplexing’ for India to reflect the way it aspires to objectives, which it then often seems to turn and work against. The contradictions are well documented (Mwanguhya Mpagi, 2014). The most compelling example of this is the state of ambulances in India (India Today, 2016; Das and Desai, 2017), which are inadequate for the excellent cardiac care provided by some hospitals.
The discussion that follows is an attempt to draw attention to the challenges and opportunities in the pre-hospital domain in India—an area in which the author has had substantial experience.
Post colonial India
India is made up of several states, cultures and societies. The condition of health care that the British left in India is a good demonstration of their legacy and priorities. The British Raj was the offspring of the East India Company; it was not surprising, therefore, that although India is 13 times the size of the UK, the number of medical schools was approximately similar (around 25) in 1947, when India gained its independence.
The life expectancy for Indians was around 30 years compared with over 60 in the UK. The progress of health care in India since independence has had its successes and failures, best represented by the following seemingly contradictory facts.
On the one hand, as a result of a massive collaborative effort in 2014, India overcame polio and was officially designated so by the World Health Organization. On the other hand, in the same year, one of the top ministers in the Indian government died in a highly-publicised car accident only a short distance away from several excellent hospitals, caused by a litany of preventable pre-hospital factors.
Adverse outcomes from traffic accidents in India are among the worst in the world. There are multiple causes for this—many in the pre-hospital care domain. The structure, especially of acute health care, is mainly hospital-based in India. Pre-hospital services are not fully developed or standardised (Das and Desai, 2017; Sikka et al, 2017). Patients have historically been expected to find their way to hospital, not least because prognosis for the acutely ill or injured was poor.
Structure and function of health care in India
The planning and implementation of health services are spread among multiple providers. Politically, India has a federal system of government with a constitutional separation of responsibilities between the centre and the state administrations. Health belongs to both; so in a cynical democratic, multi-party, combative way, sometimes it seems to belong to none.
The Indian government invests 1.2% of the GDP on health, which accounts for less than one-third of the total spend in India. In continuation of the colonial legacy, the priority so far has been on the establishment of the great institutions of care, such as hospitals and dispensaries, with additional effort on public health issues.
The modelling and planning spotlight by the government has been on the chronic diseases and maternal health, while the independent fee-for-service private sector has focused on income-generating opportunities with high and rapid returns on its investment. It is cheaper for the care provider to wait for the patient to arrive at a hospital than to find pre-hospital solutions.
The story so far
Compared with structures in industrialised and affluent countries, the situation in India might seem difficult to understand, not least because the quality of health care is often (incorrectly) visualised to reflect the infrastructure. This, however, has numerous significant exceptions. For example, often the headlines in the British press label the situation in the NHS as akin to that in the ‘third world’—whatever that means.
In theory, the number of ambulances in India meets or exceeds the number set out in WHO recommendations—yet experience on the ground does not reflect this.
Held back by several constraints, including until recently the lack of a national strategy, emergency care has been slow to develop in India. From the late 1990s, pre-hospital care has drawn more attention; partly owing to the demand and expectations of the urban elite, and partly because of the government's investment in maternity and child welfare.
Instead of finding ‘functional’ solutions suitable specifically for the Indian context, the preference has been to emulate the ‘structure’ of the Western models of pre-hospital paramedical services without a system-wide consideration of the disease burden, staffing and local cultures. There is little or no standardisation. There is no registry or definition of an ambulance or a professional pre-hospital service emergency-care provider. Beyond an enhanced first-aid training, or pre-hospital trauma life support (PHTLS)/immediate life support (ILS)-level education and training package, there is little or no internationally-accredited formal pre-hospital care qualification available in India.
Why does this matter?
So why should the international pre-hospital care community be interested in India (apart from the fact that it is hugely rewarding, enjoyable and fun—not to mention frustrating—to visit and work there)? The needs and opportunities are tremendous. With all of the caveats and cautions, financial benefits also exist (Jain, 2014; Dhawan, 2015), as many new providers are involved in developing and providing services.
Leaving aside the considerations of learning, making a contribution, researching, influencing, being creative and becoming part of an emerging world, what might one gain from engaging with the Indian pre-hospital ‘scene’? The author would suggest that it might provide academic and recruitment opportunities, in addition to evolutionary and revolutionary insights into the configuration of proper acute care provision for the ill and the injured in the second most populous country in the world, with growth forecasts of more than 5% a year (OECD, 2016).
Conclusion
The provision of pre-hospital health care in India is fragmented into at least four systems: the government/private providers at the central/local levels, each with its own focus and priority. There is no nationally accredited curriculum or academically acknowledged education and training programme. No national and local registration of ambulances or pre-hospital care providers exists.
An example
Suppose then, that someone visiting a major Indian city is taken ill or hit by a bus. Since the universal access number for medical emergencies is still in development and implementation, the person's helpers will decide whom to call from among a number of providers, including private and government-owned. How much time they take to arrive (if they do at all), is quite variable.
Furthermore, the competencies and equipment in the ambulance may exceed expectations—but on the other hand, they may not be compliant with any of the standards that would be recognised in a Western industrialised country. To which hospital the person will be taken is another matter of uncertainty, and may depend on the choice of the ambulance crew and the person's perceived ability to pay.
Alternatively, it is possible that the person may be taken in a taxi to an appropriate hospital by a good Samaritan with some training in CPR/first aid, or possibly to a less-than-ideal clinic, by a charlatan who sees an opportunity to make a fast buck on the back of the person's predicament.
If at the time of the emergency, the person is staying in a high-class hotel, he or she may be made quite comfortable while a doctor is summoned to assess and decide on what is required.
Should the person be well insured, the patient could be taken to a lovely hospital with five-star rooms. If there is insurance to cover it, he or she could be air-lifted back home or to a hospital in neighbouring Singapore.
What can be done?
In the model of the system, it is possible with the use of technology and training to get around the delays and variability of the old-fashioned ‘structural’ ambulance-based response. It is conceivable that within a system focused on delivering functionality instead of a service on four wheels, the patient in the example given in the previous section can be swiftly ‘triaged’ on-site with the deployment of appropriate assistance from the word go.
This approach for an emerging economy requires much less investment than the cost of ambulances and equipment, which go around the city only at the speed permitted by traffic jams. Needless to say, however, such a generational challenge is also the opportunity of (more than) a lifetime!