Is healthcare all about picking up sick people and giving them medication? Sadly, that's what we Indians normally refer to as healthcare. In reality, healthcare still does not exist in India. It is the practise of sickcare that we often refer to as healthcare. Healthcare is yet to make inroads in India. The total sickcare market in India is about Rs 100000 crore and is growing at 13 per cent annually.
Sickcare involves:
● Doctors , nurses and pharmacists
● Clinics, primary healthcare centres and hospitals
● Ambulatory services
● Pharmacy retail and distribution
● Disease management companies
● Medical insurance - Critical illness cover, HMO, GPO and TPAs
● Emergency and trauma care services
● Pathology labs
● Telemedicine
● Mobile labs
The addressable market for this (sickcare) is senior citizens, people suffering from chronic diseases and victims of accident and natural calamities. Typically, the age group of the people availing sickcare is above 40 years.
On the other hand, healthcare is all about serving healthy people and preventing them form getting sick. This segment addresses a huge population of more than 1 billion, especially people below 35 years of age. Healthcare is all about keeping people fit. The underlying principle about healthcare is that "health is not about absence of diseases, it is about fitness."
This segment has huge potential and covers areas such as:
● Healthcare awareness, education and counselling
● Yoga and meditation
● Fitness centres, gyms etc.
● Diet and nutrition centres /clinics
● Preventive care centres and check ups
● Health insurance
● Health supplements and nutraceuticals
● Telemonitoring and remote monitoring
In India, today, more than 1 billion people are in the age group of below 35 years. They are the main target for healthcare activities. In addition, there are people who are above 35 years and healthy and still wish to keep fit. Such kind of peoples is also active in utilising healthcare services. They embrace healthcare services as a preventive measure against getting sickness.
Future trends
With the growth of Indian economy, a new generation and class of earners have emerged. These people are from the marketing, sales, IT, ITES, BPO, manufacturing and other allied sectors, where the median age is approximately 24.5 years. These people are mostly single with an average salary of USD 7500 per annum. These are the people whose prime objective is not only to look good but feel good as well. This is leading to the unprecedented growth of national level slimming and fitness centres, gyms etc. Those who don't get into healthcare will finally be forced into availing sickcare.
The main reasons for growth of sickcare and healthcare are:
● High investments from private players into healthcare segment
● Availability of cheaper and scalable technology in healthcare
● More awareness about wellness
● High disposable incomes
● Franchise model in healthcare
● Inefficient and deficient government facilities
Classification
In any community, the population can be classified broadly into the following six categories. They include:
● Healthy and uninterested - These people are not bothered about health till they get sick
● Healthy and interested - These are the people who need solutions for fitness
● Worried healthy - These people read about sickness and fear that they are suffering from it
● Newly diagnosed - Category 1 who have not cared and fallen into this category
● Chronically ill
● Just cured
In the 1950's the average life expectancy was 30 years. Now we have taken it to 64 years. We definitely live longer and consume more pills. Moreover, India presently has a huge patient population. For instance:
● Due to acute shortage of diagnostic facilities and skilled manpower for urban poor, one out of 15 children fails to complete the first year of life. One out of 10 children born does not live more than 5-6 years. And, 60 per cent are not completely immunised
● Apart, 75.3 per cent of children below 3 years in rural areas and 70.8 per cent in urban areas are anaemic
● Two persons die of TB every minute and more than 1000 every day
● There are 2-2.5 million new patients of cancer every year
● 53 per cent of all deaths are due to non communicable diseases. According to the annual report of ministry of health and family welfare, Government of India 2006-7, 826000 people were dead of cancer, while 2980000 were kicked the bucket of CVD in 2005. While diabetes took a toll of 175000, 674000 people were dead due to respiratory diseases in 2005.
● The estimated growth of CVD is 18 per cent, while it is 35 per cent per year for diabetes
● Early data on Indian work force is alarming. Almost a third of all men and a fourth of all women have hypertension. Diabetes occurs in tenth of this population. Taking recently defined obesity standards for Indians, a whopping 50 per cent are considered over weight, and around 30 per cent suffer from abdominal obesity. 42 per cent of the men have 'bad cholesterol' and 20 per cent smoke regularly
● Now-a-days, people below the age group of 45 years constitute as much as 25-40 per cent of heart attack patients
● Studies have shown that 8 out of 10 people will succumb to back ache at some point of time in their lives
● Urban diabetes prevalence is anywhere between 5-12 per cent. Rural India has seen a growth from 2.4 per cent to 6.4 per cent in the recent years
● By 2020, cases of cardio vascular diseases (CVD) are expected to rise in India by 120 per cent in women and 137 per cent in men
How can the sector grow?
The government must ensure that healthcare gets more impetus than sickcare. Today, all major investments in healthcare are coming into tertiary care and high end hospitals. We are in fact, attending a wrong problem. We need more of preventive primary care in the country. The government must mandate all the private players that, for every 100 beds built, they must set up one primary preventive care in rural / semi urban areas.
CSR must become CCSR, compulsory corporate social responsibility. All corporate establishments posting a net profit of Rs10 crore must spend 1 per cent of it for free check up camps to be conducted in communities, schools and offices in urban and rural areas. Despite all the current hype of healthcare, about 2/3rd of the people are still not diagnosed.
Basic checks must be done for people below 30 years for obesity, TBC, hypertension, diabetes, cholesterol and cancer detection. This in itself will lead to the early detection and prevention of borderline cases of many ailments. This can be a boon for the path lab and pharmaceutical industry, as this will bring in millions of people who are suffering but still undiagnosed. So the companies in this segment must play a proactive role than just bribing doctors (directly and indirectly). These companies must look at DTC /DTP (direct to patients / consumers).
Tax relief: Must not just be given for health insurance but also for preventive health check ups. In fact, it must be more for preventive health check ups and less for health insurance when compared. This will bring down the healthcare cost for individuals and the governments.
Telemonitoring: Health screenings via telemedicine should be given a major thrust. This will lead to the better management of health, patient compliance, reduced emergency visits and costs and optimised use of existing resources and time for patient management. Home monitoring program has resulted in 35-75 per cent reduction in emergency room visits in US. Indians today spend 8.2 per cent of their total household expenditure on healthcare and 72 per cent of the Indian population still lives out of urban India.
NGO's must come up in the health monitoring space and play a key role as government has its own limitations on delivery issues in healthcare.
Pharmacy retail and distribution: It needs a greater thrust as the end consumer today is at a big loss. The storage conditions are blatantly violated and approximately 25 per cent (one out of four medicines) medicines sold in India is either sub standard or spurious. We have no count on how many lives are lost as a result of the deficient and inefficient supply chain. It calls for consolidation and revolution. Even if the top 30 pharma companies come together (top 30 companies control approximately 65% of the trade), the supply chain can get transformed into 'demand chain management' thereby eliminating the ills of the business. Generics should be encouraged to grow at the same time lowering the cost.
Disease state management (DSM): In USA and other developing countries DSM is a big market, where the employer or government pays for the healthcare costs. But in India about 92 per cent of the healthcare expenditure comes from individuals' pocket. DSM is known to change patient behaviours and environments and lead to better compliance and fewer hospital admissions. It thereby reduces healthcare costs and saves lives. It is imperative that India considers the disease management route to the management of chronic care. Health insurance companies must adopt DSM as a compulsory offering to its policy holders.
National level chain of centres of immunization, family planning, pain management, day care, minor surgery and dressing clinics, dialysis, chemotherapy, maternity clinics, ophthalmology, drug de-addiction, smoke cessation clinics and diet and nutrition need to come up to provide focussed care. Then admitting everyone into hospitals is not a must. Hospital set ups are also a deterrent for many people to get themselves treated. Today, if you want to get yourself checked for BP, basically you have only a few options like doctor clinic, hospital etc.
Today every major healthcare players, be it Apollo, Fortis, Max or Wockhardt, are just looking at tertiary care. But government must ensure that the primary care matches up with the growth of tertiary care. The building cannot be strong if you build the third floor (tertiary care facilities) without building the strong foundation (primary care) and first and second floors (secondary care and allied specialty services). The government must step in to give more incentives to people who bring out all the services in an integrated manner, i.e., primary care, secondary and tertiary care.
In fact, in the preventive care the set up cost is low, returns much higher and scaling up is much faster. It is a proven fact that early diagnosis of borderline cases can be treated with just minor modifications in lifestyle and diet. The government only needs to give a push. PPP is required for primary care in India. Preventive care will result in improving the quality of life and will increase the life expectancy.
Advertising laws need to be changed so that the pharmaceutical companies and healthcare providers can create awareness about various disease states by advertising their pharmaceutical / healthcare products. We must take into account that 50 per cent of all the medicines prescribed are not taken. Healthcare and preventive care education needs to be a part of elementary school curriculum to make people understand the importance of health at an early age. That will to a large extent solve a major part of our country's healthcare problem.
(The author is vice chairman of Heartline Telemedical Services PTE, Chennai)