Public Health Systems

For any society to grow and prosper an essential requirement is that its citizens remain healthy. Good health is not only a blessing but is essential both for living life to its fullest as well as productively. Public Health Systems is to do with how health care could be organised and managed towards this end, and is a specialized field of management. Of course, involvement of doctors and medical professionals would bring in domain knowledge and expertise which would be essential for a functional and equitable Public Health System to evolve.

The US model of health care is much talked about and we in India seem to be so enamoured by it that we are bent on aping it without really understanding it, as there is much in it which is truly disappointing.

The Nobel Prize winning economist Prof Stiglitz has commented in one of his essays (Ebola & Inequality, The Great Divide),“America’s largely private health care system is failing. ... True, at the top end, the US has some of the world’s leading hospitals, research universities, and advanced medical centers. But, though the US spends more per capita and as a percentage of its GDP on medical care than any other country, its health outcomes are truly disappointing. ... American male life expectancy at birth is the worst of 17 high-income countries – almost four years shorter than that in Switzerland, Australia, and Japan. And it is the second worst for women, more than five years below life expectancy in Japan. ... Other health metrics are equally disappointing, with data indicating poorer health outcomes for Americans throughout their lives. ... Good health is a blessing. But how countries structure their health care system – and their society – makes a huge difference in terms of outcomes.” 

This aspect of the dysfunctionality of the US Health System has also been commented upon by Dreze & Sen in their book, An Uncertain Glory. In their words, “The US health care system is one of the most costly and ineffective in the industrialised world: per capital health expenditure is more than twice as high in Europe, but health outcomes are poorer with, for instance, the US ranking 50^th in the world in terms of life expectancy". 

These viewpoints prompts us to examine some aspects that are desirable in designing an efficient and effective public health care system by incorporating elements of current thoughts in management theory and economics.  First, since health-care professionals require long and high levels of training, there is and would always remain high levels of asymmetric information between doctors and patients. That is, doctors have much more information available with them on the patient’s health and the possible future course of action than the patient has about herself. To remedy this, doctors have been given the responsibility to fully inform the patient of the treatment protocol before starting any treatment. This sounds very nice in theory, but is practically impossible to follow. A case of wishful thinking which is bad thinking as it leads to little wish fulfilment. In treating any patient, there are various possible therapeutic options between surgery, medication, life-style changes, radiation, or doing nothing at all. Even the specific medication can vary. Doctors decide on the required investigations and most appropriate treatment regime based on age, medical and socio-economic condition, co-morbidities, previous drug regime, possible follow-up treatments which would be required etc. etc. It is impossible both for the doctor to explain all this succinctly to patients given their heavy work-load as well as for patients to understand it given their limited knowledge of the nuances of medical treatment.  In deciding on the treatment protocol doctors bring in years and decades spent on their education and training – which as is well known is time taking and strenuous.

Second, to ensure doctors prescribe the most cost-effective and suitable treatment, they need to have the right incentives. Due to high levels of asymmetric information the scope for perverse incentives is very high. What that means in plain English is that doctors, like any other human being, will have an incentive to prescribe expensive procedures if it benefits them personally, given a chance to do so. As is well known, in corporate hospitals there is a well laid out practice of laying revenue targets for all consultants. It therefore very naturally directs them to prescribe all kinds of diagnostic investigations and the most elaborate treatments so as to inflate earnings.

Any stable, equitable, widely available, self-sustaining health care programme has to explicitly take these two factors into account. 

Some very specific instances how this plays out in real life come to mind, both good and bad. In one case, I was having high fever and was worried since I had some travel plans. I therefore went and met a doctor - a GP. He examined me and pronounced, “I can see no evidence of any kind of bacterial infection. In all probability, you have some kind of virus infection. Go home and take rest. If the fever does not go down on its own in three days, come back. If it goes above 100° F, take a paracetamol.

In another case, my brother had been diagnosed with some very serious kidney ailment and it set off a long chain of visits to various doctors. At every stop, it was standard for the doctor to prescribe two things – a blood test to check urea and creatinine levels and an ultra sound report of the kidney. Mind you a fresh one for each doctor we visited. There seemed to be no end of it and there was no resolution in sight. Finally, based on suggestions with friends we made a trip from Patna to Chandigarh to meet a specialist. Over 15 minutes this doctor discussed his issues with my brother and then proceeded to physically examine him over the next 10 minutes. Then he announced his verdict and prescribed a line of treatment. We were a little aghast and I bluttered out, “aren’t any tests required?” The doctor just smiled and replied, “I have seen all that was to be seen”. Later I came to know that this doctor had diagnosed the condition of the kidney by tapping the back and the levels of urea and creatinine by examining the eyes.

Now a couple of horrible experiences.

A very close friend of mine had been diagnosed with end stage liver cancer. As friends we discussed the situation, and then he asked me to be the executor of his “living will”. That is, he gave me the legal authority to take some decisions on his behalf in case he became incapable to doing so.  He was clear that he should not be put on life support and he gave me the written authority to take him off life support, if required. His logic was that his sons were young and might not be able to take this difficult decision. The inevitable happened. His condition took a turn for the worse and his sons rushed him to the hospital, and also called me. By the time I reached the hospital my friend had been put in the ICU and was being given all kinds of very expensive treatments. I approached one of the senior consultants in this hospital, who I personally knew very-well, and is a very fine human being, with the request that he be taken off life support. The response was most unexpected. I was informed that if the hospital did so, they may be charged with murder and as such would not and could not do it. I also came to realise that going the legal way to execute the living will was an extremely cumbersome and time taking process and practically impossible. I spent four days in extreme mental agony at having failed a friend in fulfilling a promise I had made. Over these four days, my friend was in complete vegetative state in the ICU. Thankfully he died on the fourth day. The hospital in the meanwhile ran up a bill of around Rs.5 lakhs and deigned to release the body only after the full payment had been made.

A relative had been ailing for quite some time (over 7 years) and I accompanied her on a visit to meet the consultant at a very reputed corporate hospital. After examining her, the doctor advised, that he suspected colon cancer, and to verify which she would have to be admitted for a couple of days. I asked this gentleman, given the patient’s existing condition would it be possible to give any kind of therapeutic treatment – surgery or chemo or radiation – if the diagnosis was confirmed. He was kind (and brave) enough to accept that there were practically no treatment options available in her condition. We brought her home and gave her all the love and care we could manage and she passed away peacefully at home three months later.

In medical circles, the rule of thumb is that any investigation or treatment should be prescribed, if and only if, it would result in helping the patient in any way. Something which is very conveniently forgotten in the corporate health care environment.

We, as a society swear on the glamours of corporate form of managing human organisation as being the most efficient and effective way of doing things. However, there is another vision of the corporation – one which is truly frightening.

In a film titled, The Corporation, the three Canadian co-creators, Mark Achbar, Joel Bakan and Jennifer Abbott, ask the question that, if a corporation is a person, what kind of person would it be?  The Economist in its edition dated 6^th May 2004 sums up the conclusions of the film in these words, “…the corporation is a psychopath. Like all psychopaths, the firm is singularly self-interested: its purpose is to create wealth for its shareholders. And, like all psychopaths, the firm is irresponsible, because it puts others at risk to satisfy its profit-maximising goal, harming employees and customers, and damaging the environment. The corporation manipulates everything. It is grandiose, always insisting that it is the best, or number one. It has no empathy, refuses to accept responsibility for its actions and feels no remorse. It relates to others only superficially, via make-believe versions of itself manufactured by public-relations consultants and marketing men. In short, if the metaphor of the firm as person is a valid one, then the corporation is clinically insane.”

Therefore, is there a better way to move forward!

I would like to take the help of some financial economists in trying to find a possible solution. Shleifer & Vishny argue in their paper, A Survey of Corporate Governance (The Journal of Finance, June 1997), that, “We have suggested that, in some situations, concentrated ownership may not be optimal because non-shareholder constituencies such as managers, employees, and consumers are left with too few rents, and too little incentive to make relationship-specific investments. In these situations, cooperative might be a more efficient ownership structure. …  This logic has been used to explain why health care, child care, and even retailing are sometimes best provided by cooperatives”. 

Privatised health care systems are a classic example of concentrated ownership with all stakeholder other than the promoters (who are generally top-notch consultants or private equity invetors), having little say in the functioning of system. The ones left out from having a say include junior doctors, nurses and other support staff, and of course the patient. Since large investments are required to set up and run these entities, they are left with no choice but to seek to generate large returns - by any and all means. Meanwhile, the bulk of the staff, ie all than the top consultants, have to put in long hours and much labour at low pay. In the process their prime objective - health care - is effectively bypassed.

One possibility which can and should be explored is to organise primary health care through cooperatives. Individual GPs can set up their own private clinics while being a member of a cooperative society. The coop could help out by maintaining quality standards, common clinic design standards, bulk procurement of consumables and durables, and arranging easier access to credit.  The coop brand name would also help in reassuring prospective patients of being offered certain minimum care standards.

Since the owner manager would have a large say in the functioning of individual clinics, the kind of pulls and pressures doctors face in working in corporate hospitals become much less. At the same time, they would have organised support from the cooperative of which they are a member which would help them set up and stabilise their clinics. Once the system of standalone clinics start functioning and become stabilised, larger secondary and tertiary care health care systems may be thought of as extensions of the same model.

Unfortunately, the way we have built up our cooperative system over the last century plus, they have become a cesspool of corruption. To bring out its true potential, re-orientation of the cooperative philosophy from a means of doing charity to a system of organising human endeavour would be required.  Changing the mindset would take much time and effort, but a start can be made - keeping the success of the milk cooperatives as an ideal. 

On Killing A Tree - The Chevella Banyans

A Chevella Banyan

I first read Gieve Patel’s poem, On Killing a Tree, over 45 years ago. It was part of my final year school syllabus. This is one poem which has not stopped haunting me ever since.

On Killing a Tree by Gieve Patel

It takes much time to kill a tree,

Not a simple jab of the knife
Will do it. It has grown
Slowly consuming the earth,
Rising out of it, feeding
Upon its crust, absorbing
Years of sunlight, air, water,
And out of its leperous hide
Sprouting leaves.

So hack and chop
But this alone wont do it.
Not so much pain will do it.
The bleeding bark will heal
And from close to the ground
Will rise curled green twigs,
Miniature boughs
Which if unchecked will expand again
To former size.

No,
The root is to be pulled out -
Out of the anchoring earth;
It is to be roped, tied,
And pulled out - snapped out
Or pulled out entirely,
Out from the earth-cave,
And the strength of the tree exposed,
The source, white and wet,
The most sensitive, hidden
For years inside the earth.

Then the matter
Of scorching and choking
In sun and air,
Browning, hardening,
Twisting, withering,
And then it is done.

A few days ago, I attended a meeting of enthusiasts who have organised themselves under the banner of “Save the Banyans of Chevella” in an attempt to protect thousands of gorgeous trees - especially old and mature banyans - marked to be axed for road widening on the Hyderabad-Chevella-Bijapur highway in Telangana, India. To know more about this effort, visit their blog. 

The meeting at Lamakaan.

These are a set of huge and magnificent trees, planted more than a 100 years ago of which only around 900 still survive. In the name of “development”, the proposal is to cut down these trees and widen the highway, which would reduce travelling time and scope of accidents. In addition, the land prices along the road are increasing exponentially, in view of its easy connectivity with the upcoming parts of Hyderabad. This in turn gives substantial tangible benefits to those owning land in these areas, apart from real estate developers and politicians who are salivating at the prospect of making a kill.

One of the magnificent Chevella Banyans.

On the other hand, saving these trees is considered critical and essential due to a variety of reasons – and that is what these volunteers are fighting for. As we all know trees provide a huge number of benefits, and without trees survival of the human race itself would impossible. They provide shade, help to bring down local temperatures, maintain climate, attract rain clouds, nurture a whole ecosystem of insects, birds, and other animals again whose survival is essential for maintaining ecological balance and in turn our own survival.

Professor T M Das of the University of Calcutta has estimated the monetary worth of a single adult tree as at much as Rs.1.25 crores after factoring in the numerous benefits silently bestowed on us by trees. These include the contribution of trees in generating oxygen, controlling pollution, increasing soil fertility, providing shelter to human and animals, and acting as giant sponges in absorbing rain water and enabling their slow percolation into the underground aquifers.  

A signboard at KBR Park, Hyderabad.

The Save Chevella Banyans project is a great example of how private citizens with very limited means, juggling families and work, have come together to take on the might of entrenched political and economic forces, who in their short-term perspective are bent on destroying our collective heritage. The ask of the volunteers was simple – please change the alignment of the road so that these trees do not have to cut down.

One of the arguments put forward by the NHAI was that they would arrange to transplant these trees. At best this is an extremely specious argument for a number of reasons. First, these are huge fully grown trees and translocating them is remotely not an easy task. Second, translocation of fully grown trees involves cutting down most of the branches and leaves, so that water loss due to respiration is reduced to the minimum while the translocated tree adjusts to its new home. This at one shot annihilates all the life which is being supported in those branches – insects, birds, small animals etc. Third, translocation of trees involves cutting off most of the roots. The roots are underground and so we do not see them, but they are roughly of the same size and depth as the part of the tree which is above the ground. It is impossible to save the roots, especially the thin sensitive ends through which the trees draw water and minerals for its sustenance. What is left is the root ball which is normally insufficient to really ensure survival of the tree. To remedy which artificial hormones are injected into the tree. Inspite of all such measures, the long-term survival percentage noticed in translocated trees are barely into lower end of two digits.

The first hurdle was that there seems to be no specific laws which prevent the cutting down of trees for road widening. For building up their case, the volunteers geo-tagged each and every of the Chevella Banyans. Then the volunteers appealed to the Southern Bench of the National Green Tribunal Bench, who - surprise of surprises, heard them out and directed NHAI to complete a detailed and ‘special’ study (Environmental Impact Assessment) to find alternative means to ensure that the 750 Banyans are safe and sound. The order does not support any uprooting or cutting of these trees until such a report is submitted to the tribunal at the earliest. The 700-odd Banyans mentioned in the order are the trees that will be impacted by the road-widening; there are another 200 trees that are unaffected as the present alignment does not reach them.

The status today is that NHAI has done some kind of EAI and is now proceeding with the road widening project which includes cutting down most of these magnificent trees. The meet which I referred to in the beginning of this blog was to generate ideas on how to prevent such destructive action

Nearly all of us react much more strongly to things and events which affect our immediate environs or which appeal to us emotionally. As such, sustaining human interest on Chevella Banyans is difficult, even if the issue is extremely important. Few Hyderabadis travel on that road and as such have little emotional attachment to them. To build public interest, instead of focusing only on the Chevella Banyans, if the interest of the group was on saving trees and the messaging was directed on the importance of doing so, it would bring much more public participation.

The flip side would be that the focus of attention on the Chevella Banyans might get diluted or even lost. To remedy which, the Save the Chevella Banyans group should consider to change its name and identity to something like Friends of Trees / Tarun Mitra for bringing awareness of the important of trees. It could promote tree planting / maintenance, but simultaneously an identified core group should be tasked for concentrating on saving the Chevella Banyan project.

Be what may be – savings the Chevella Banyans is an issue worth fighting for.

Roads & Us

According to the 2021 World Bank commissioned report, Traffic Crash Injuries and Disabilities : The Burden on Indian Society, India has 1% of the world’s vehicles but 11% of all road accident deaths. As per the Ministry of Road Transport and Highways Report titled, Road Accidents in India – 2022, based on the data/information received from police departments of various States/UTs, in 2022, a total of 4.61 lakh road accidents occurred in India, leading to 1.68 lakh fatalities which left 4.43 lakh people injured. These figures represent an 11.9% year-on-year increase in accidents, a 9.4% rise in fatalities, and a surge of 15.3% in the number of people injured compared to the previous year.

It is widely believed and highly probable that the figures given out by GOI are under-estimations on account of large under-reporting of accidents. It is estimated that currently every year, approx. 2 lakh Indians die in road accidents, i.e., around 22 every hour, one every three minutes. Around 3 times as many (approx. 6 lakhs) get injured requiring hospitalisation or ending with permanent incapacitation, ie, 60 every hour – one every minute. One of the prime causes of this dismal picture is not following basic traffic discipline and poor understanding of road safety rules, apart from poor design and maintenance of roads. 

Somehow all our analysis on traffic safety starts and ends with two or three standard prescriptions. Wear helmets, put on seat belts, and drive slowly. Such precautions help to reduce the intensity of accidents – they do little to prevent accidents. After all, prevention is better than cure.

Travel on any public road in India, and you will find people driving blissfully while talking on their cell phones, driving on the wrong side of the road, using high-beam within town / city limits, rarely using side-indicators while turning (leave alone while changing lanes), overtaking from the left etc. etc. I could rant on and on, but I would like to spare me readers from this torture. 

The concept of right-of-way, say, which vehicle has priority when two vehicles meet at a crossing or the fact that pedestrians have right-of-way at zebra crossings is conspicuous by its absence. I doubt that even one in hundred experienced driving license holders in India would be even aware of this concept. The lack of knowledge of such nuances is also likely to be high among those whose job is to ensure our traffic moves smoothly and roads are accident free – traffic policemen, driving instructors, or driving licensing authorities.

A quick sample survey of the level of understanding of traffic rules by traffic policemen and licensing authorities would easily throw up the extent of gaps in their knowledge. Educating and training them should then be the first line of action in improving traffic discipline and thus preventing accidents. 

The low level of awareness of basic traffic discipline manifests itself in various pathologies on our roads on a continuous basis. Mounting cases of road-rage leading even to murder is one. Or vehicles and pedestrians moving haphazardly and weaving in and out of traffic significantly slowing down average traffic speed and hurting everybody by wasting commuting time and increased fuel usage is another. Moreover, this leads to inefficient use of scarce and expensive road infrastructure, decreasing the return on their investment as well as the average speed of traffic movement. These are very tangible and large economic losses to society but are rarely factored in, in any discussion on road safety. Studies carried out by the Ministry of Road Transport and Highways (MoRTH) have estimated that traffic crash costs alone may be equivalent to as much as 3.14 percent of the national GDP.

Controlling this Frankensteinian monster is imperative and needs a multi-pronged approach. First, is to increase level of understanding of traffic rules and discipline across users, second is to reduce the pressure on available road infrastructure by putting in more investment in public transport systems – buses, trams, and metros so as to make them more user friendly, and third is to improve the design of our roads and road signs.

It is likely that the savings in costs by having faster moving and less congested roads by having good public transport systems may be greater than the subsidies that governments put in public transport networks.

Some low hanging fruits for improving public transport usage include, having more and better intra-city buses, having functional bus stands and ensuring that the public buses stop there. The bus-stops should prominently display the name of the place and the bus numbers and routes of buses plying through it. Very often we see that bus-stops are full of garish advertisements but essential information which would enable easier travel is either missing or difficult to locate. It would also be extremely helpful if all bus-stands have a schematic diagram of the major bus routes which would enable passengers to easily figure out which route / bus numbers to board to reach say from point A to B. Some bus-stops in Bengaluru and all bus-stands in Paris and other major European cities have this. 

We should also consider equipping all bus stands with an electronic display which would provide information in real time as to which bus number is expected at what time, say, over the next one hour. This would greatly help commuters to plan their travel plans. Considering that most public buses are now GPS enabled, India with its aspirations to be the IT hub of the world can easily devise such a mechanism, something which is common place in many European cities.

Talking about public transport, there is much that can be improved in our metro train systems. I will save that for another day.