In August 2017, parents watched helplessly as more than 60 babies, diagnosed with encephalitis from mosquito bites, died due to lack of oxygen at a hospital in Gorakhpur, UP, because suppliers’ bills of INR 68 lakhs had not been paid. Such news is made even more tragic when India, in stark contrast, claims to be the lowest cost provider of the highest quality care in the world.
Post such an event, questions get raised and the usual causes get flogged in public: corrupt administrators, low government spend, poor sanitation, incompetent or absent doctors, inadequate supplies, etc. After an appropriate period of ennui, the nation moves on until the next tragedy that is inevitable and imminent.
Gross negligence and such obvious causes, though difficult to digest, are easy to understand. Our real quest, the Holy Grail, should be to eliminate any and all errors that prevent us from delivering the best modern science has to offer and delivering the same to all. Anticipating and correcting or preventing the errors created in healthcare delivery systems is a larger systemic challenge. The healthcare system is characterized by several major factors that are enlisted below.
Knowledge
First, there is the science of medicine. There are estimated 10,000-30,000 diseases known to us that affect humans, of which only a few (500-1,000) have a known cure. There are over 4,000 diagnostic lab tests, over 400 imaging tests and interventions, about 12,000 drugs, approximately 600-1000 procedures. Medical practitioners build up their skills over 60 main specialties and several hundred subspecialties. This knowledge base is constantly updated and modified so fast that even the best practitioners find it very hard to keep up.
Complexity
Then we have the complexity of the vulnerable and disease-prone human system that is designed to die from the moment it is born. Over 100 billion cells, 78 organs (11 complex large organs) and 12 interdependent systems make the human body – ever-changing, continuously monitoring, detecting, and self-healing. The National Institute of Health, USA now estimates that over 400,000 people die unnecessarily each year in the US alone due to medical errors making it the third leading cause of death.
Environment
Last, but not least, we have the environment; viruses, fungi, and protozoa. Add to this diet, sunlight, exercise, nutrition, stress, sleep, road accidents, murders, and natural calamities.
This vastly-complex intersystem of medicine, the human body and environment is also both dynamic and fast changing. The human body is subject to more stresses, less rest. The environment is more toxic, the air more polluted, the food more artificial (with high sugars and high hormones), medicine is more segmented and intrusive. All of this creates the market conditions for supply and demand of healthcare. We are willing to pay for the right to live a little longer. Sanitation, vaccinations, antibiotics, heart surgery, wound management, and healthier diets and environment have helped us raise our life expectancy from 30 to current 78 years. But this is neither uniform nor guaranteed at an individual level.
Modern healthcare seeks to remedy this through practiced carefully prescribed established best practices that deliver near-zero errors for all aspects of healthcare: preventive, diagnostic, interventional, progressive and palliative.
The System Of Profound Knowledge® (SoPK) propagated by W. Edwards Deming lays the foundation for any large complex system in four parts: System, Variation, Knowledge and Motivation.
Many-to-many interactions
A typical healthcare intervention consists of a 4-day admission into a 400-bed hospital during which stay you get “managed” by over 40 different persons across 175-200 encounters. This takes place across multiple specialties, multiple diseases, multiple drugs, procedures, and tests. None of these result in absolute guarantees. A reasonable large variance in each encounter can result in the same event being interpreted, acted, and monitored in completely different ways by different persons (the knowledge and competency of and tools available to doctors, nurses, technicians, management, ward boys, pharmacists etc.) Finally, there is the inherent lack of congruence on motivation on the part of the patient (the consumer) and the rest (the payer and the provider). Efficiency vs. effectiveness, today vs. tomorrow, cost vs. profit, need vs. greed, and the strange but compulsive desire by all humans to outsource their mistakes and seek a free ride on someone else’s goodwill.
Variability
Healthcare systems have a vast multitude of parameters with a range of possible values that create an inevitable variation of results built into the design, interpretation, intervention, and prognosis.
Availability
Hospitals operate 24/7 but are not fully functional at night or weekends. Patients, on the other hand, need urgent instantaneous care (be it advice, first aid, trauma, or acute pain). Patients often commute for 1-24 hours, wait for 15-45 minutes, only to see a doctor for 2-15 minutes.
Incomplete
Information is at a premium when the time is of essence. But it is often the least available when most needed. Latest lab results, adherence to current medication, a detailed symptomatic history, past medical conditions, genetic profiles, latest best practice evidence. Most of the time the healthcare provider is working with less than the full picture.
Affordability
Many agencies have recommended that the government spend of 1.1% of GDP be increased immediately to at least 2.5% and eventually to 3% of GDP. Each year over 55 million people go bankrupt due to healthcare expenditure, most of which is due to the cost of medicines. Before we get the increased spend we need to be prudent and pragmatic in how we spend rather than how much.
If we take a systemic view of healthcare and improved it from first principles with a strong foundation on education, sanitation, primary and preventive care, we could stretch the healthcare spend to reach millions more and lift the nation to a higher global standard that each citizen truly deserves. In order to reduce the complexity, narrow the variability, increase the availability, improve the know-how and complete the gaps in information at the point of care, we need to invest more in digital health tools than increasing beds or doctors. Ayushman Bharat is a welcome program designed to fix the twin challenges of affordability and access to 10 crore families across India.
Metrics
What gets measured gets improved. The complexity that arises in healthcare leads to an enormous list of metrics all which claim to improve health care: Beds per 1000, doctors per 1000, cost of an inpatient stay for each procedure, toilets per family, nets in mosquito-friendly regions, lab tests per person, out-of-pocket spend, Healthcare spend as a percent of GDP, infant mortality rates, and maternal mortality rates.
The 910 bed Bokaro General Hospital (BGH) run by SAIL has one of the best neonatal care facilities in Asia, but has one of the worst records for neonatal deaths. Just 10 minutes away is the Sadar Government hospital that had the best record for neonatal deaths: ZERO. The entire result can be attributed to the well-meaning, Good Samaritan intervention of the rickshaws near the government hospital who nightly transfer high-risk women in severe distress to the better facility at BGH. A few get saved, many die as it is too late but the government hospital manages to keep its record intact. What can be counted doesn’t always count, and not everything that counts can be counted.
Biography of the Author
Udai Kumar, is the Chairman & CEO of OHUM Healthcare Solutions, is a highly successful serial entrepreneur, mentor, and investor. He brings almost 28 years of IT industry and entrepreneurial experience. As the Founder of OHUM and cofounder of QUINNOX, Udai has a deep understanding of the global delivery model and specializes in global business development, human capital management, finance, software development, Six Sigma, systems & processes. Udai holds a Masters in Business Administration from the Indian Institute of Management (IIM), Ahmedabad, India and a BS in Engineering from Banaras Hindu University, India. He was engaged in Sales, design, development & deployment of the three largest IT projects in India – Railway Reservations, Bombay Stock Exchange & Nhava Sheva Port Trust. Udai is an active member of the Health Information Network group and is on the panel of Leadership Team at the Government of India level for healthcare technology.
