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Healthcare
in IndiaCaring for morethan a billion
Executive summary
Healthcare
IBM Institute for Business Value
IBM Global Business Services
Toreceiv
eacopy
ofthe
fullreport,please
visit
ibm.co
m/health
care/hc2015
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IBM Institute for Business ValueIBM Global Business Services, through the IBM Institute for Business Value,
develops fact-based strategic insights for senior business executives around critical
industry-specific and cross-industry issues. This executive brief is based on an
in-depth study by the Institutes research team. It is part of an ongoing commitment
by IBM Global Business Services to provide analysis and viewpoints that help
companies realize business value. You may contact the authors or send an e-mail to
[email protected] for more information.
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India has had notable health achievements
since independence in 1947. Lie expectancyhas doubled and inant mortality and crude
death rates have been greatly reduced.1 Some
diseases, such as small pox and guinea worm,
have been eradicated. Others, such as leprosy
and polio, have been nearly eliminated.2 And
Indias doctors and hospitals are increasingly
receiving recognition or the quality o care
they provide.
Nevertheless, India aces considerable
challenges. For example, the country accounts
or a relatively large share o the worlds
disease burden.3 And while Indias burgeoning
middle class has greater access to excellent
healthcare, the vast majority o citizens still
have limited access to basic care. The quality
o care varies signicantly, as well.
An examination o healthcare systems in
other countries underscores the importance
o achieving a value-based, aordable,
sustainable healthcare system in India. In a
recent study by the IBM Institute or Business
Value, we demonstrated that unrelenting
pressures are pushing many healthcare
systems along an unsustainable path.4 I
let unaddressed, many countries will reach
a breakpoint in their current paths, orcing
immediate and major orced restructuring.
What does this mean or India?
Without signicant changes, an unsustainable
path or India could have public health,
economic, social and political ramications.
For example, despite signicant investments,the healthcare inrastructure will likely remain
ragmented, ocused on acute, reactive,
episodic care and will be inaccessible or
many, particularly in rural areas. And the
insucient healthcare delivery capacity wouldbe exacerbated, as providers are burdened
by such issues as workorce shortages and
overcrowding.
Fortunately, a more positive scenario is
possible. However, it will require new levels
o accountability, tough decisions and
collaborative hard work on the part o all
stakeholders.
To help India avoid a healthcare crisis, we
recommend:
Healthcare providersexpand their current
ocus on episodic, acute care to encompass
the enhanced management o chronic
diseases and the lie-long prediction and
prevention o illness.
Citizensmake wiser health choices and
increase the value they receive rom a
transormed healthcare system.
Payershelp consumers remain healthy and
get more value rom the healthcare system, as
well as assist care delivery organizations and
clinicians in delivering higher value healthcare.
Supplierswork collaboratively with care
delivery organizations, clinicians, and patients
to produce products that improve outcomes
or provide equivalent outcomes at lower costs,
particularly or diseases endemic to India.
Societymakes realistic, rational decisions
regarding liestyle expectations, acceptable
behaviors and privacy policies as well as
the degree healthcare will be a societal right
versus a market service to provide all Indians
at least environmental and basic healthcare.
Healthcare in India: Caring for more than a billionExecutive summary
To download a complete copy
of Healthcare in India: Caringfor more than a billion,
please visit www.ibm.com/
healthcare/hc2015. The full
report includes a detailed
description of the drivers that
are changing the status quo
and that must be addressed,
as well as a hierarchy of
healthcare needs, principles
to guide transformation, a
vision for Indias healthcare
system, implications and
recommendations for keystakeholders (e.g., care delivery
organizations, doctors and other
care givers, consumers and
government) and more.
1 Healthcare in India
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2 IBM Global Business Services
Governmentaddresses the unsustainability o
the current system by providing the leadership
and political willpower to remove obstacles,
encourage innovation and guide the country to
sustainable solutions.
I stakeholders can act with accountability
and demonstrate the willingness and ability to
change, they can better harness the drivers o
change and achieve a win-win transormation.
Indias healthcare system can help its citizens
lead healthier, more productive lives, as well
as contribute to Indias ability to compete
globally. It can also help India win a competitive
advantage in the emerging global healthcare
industry.
Ingredients of a win-wintransformationAction and accountability are the basic
ingredients o change. To create a win-win
transormation in its healthcare system, we
believe India should undertake the ollowing
actions (see Figure 1):
Focus on value Consumers, providers
and payers should agree upon the deini-
tion and measures o healthcare value and
then direct healthcare purchasing, health-
care services delivery and reimbursementaccordingly.
Develop better consumers Consumers
need to make healthier liestyle choices and
become more astute purchasers o health-
care services.
Create better options for promoting health
and providing care Consumers, payers
and providers should seek out more conve-
nient, eective and eicient means, channels
and settings or health promotion and care
delivery.
A clear accountability ramework enables
these actions. Accountability must span the
system, including the provision o adequate
healthcare nancing and rational policy,
the adherence o healthcare proessionals
to clinical standards and quality care, theencouragement by payers o preventive and
proactive chronic care and the responsibility
by citizens or their own health.
The value transformation
Value is in the eye o the purchaser, but,
today, value in healthcare is dicult to see.
For example, data regarding quality is scarce
and mostly anecdotal or incomprehensible.Compounding this is the prevalence o
multiple orms o medicine, rom allopathic
medicine to more traditional, less regulated
orms such as Ayurveda, Yoga and
Naturopathy, Unani, Siddha and Homoeopathy
To complicate matters, the purchasers and
beneactors o healthcare consumers,
payers and society all have dierent opinions
as to what constitutes good value. Balancing
and resolving these conficting perspectives is
one o the major challenges in the successul
transormation o a healthcare system.
Win-Win
Transformation
Tran
sformin
g
Tra
nsform
ing
Transf
ormin
g
Value
Consum
erRes
ponsibility
CareD
elive
ry
Source: IBM Institute for Business Value.
FIGURE 1.
Keys to a win-win transformation of Indiashealthcare system.
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3 Healthcare in India
Today, consumers are largely responsible
or bearing the costs o healthcare, and their
ability to predict healthcare quality is equivalent
to a roll o the dice. Payers consumers,
public or private health plans, employers
and governments shoulder the burdeno healthcare costs, but have largely been
disintermediated rom or disinterested in the
quality o care discussion.
In the win-win scenario we envision,
consumers will assume much greater
responsibility or their healthcare, which, in
turn, will drive the demand or value data that
is readily accessible, measurable, reliable
and understandable. In response, payers will
help empower consumers by enabling greater
transparency into care costs and quality.
In the absence o pressure rom consumers
or payers or greater scrutiny, most providers
have not been orthcoming in providing
data around value. Recently, however, some
voluntary disclosures have emerged as some
corporate hospitals have begun to pursue
accreditation rom organizations such as the
National Accreditation Board or Hospitals and
Healthcare Providers (NABH) and the Joint
Commission International (JCI) in order to
promote their adoption o quality standards.
Payers also will take a more holistic view o
value looking not simply at the episodic costs
o procedures, but at how investments in high-
quality preventive care and proactive health
status management can improve quality and
help minimize the long-term cost structure o
care.
Finally, society will demand that payment or
and quality o healthcare services be aligned
to the value those services return, both to the
individual and to the country as a whole.
The consumer transformation
The second key element in the win-win
transormation o Indias healthcare system
is increased responsibility by consumers or
managing their healthcare services, as well
as their personal health management. AsIndia is pressed ever closer to the edge o
a healthcare crisis, the pressure is building
or consumers to change counterproductive
health behaviors and actively participate in
their healthcare decisions.
Today, consumers are not usually able to
dene value in healthcare. Some do not care
what healthcare costs because they see it
as ree or prepaid. Some do care, but nd
it prohibitively dicult to access meaningul
inormation they need to make sound choices.And many others do not have the health
literacy skills required to navigate these
choices.5
Compounding the problem is the disregard
by a segment o the population or healthy
liestyle choices. For example, tobacco use
is high in India, despite government eorts
to curtail this. Indians should be actively
engaged to combat illnesses and conditions,
especially since liestyle behaviors are a major
contributor to health status.
In the win-win scenario, we believe consumers
should increasingly comparison shop or
healthcare in the same manner they shop
or other goods and services. Liestyle
choices will also be more explicit, with poor
choices being accompanied by short-term
consequences.
Health infomediaries, or coaches, who help
patients identiy the inormation required to
make sound choices, interpret medical and
nancial inormation, choose between care
alternatives and channels and interact with the
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4 IBM Global Business Services
Among the poor, the ocus must be on
prevention and the achievement o improved
health status in terms o water supply,
sanitation, nutrition, access to vaccines,
vitamins and other low cost, but vital, services.
Preventive care may also be delivered by
midlevel providers including physiotherapists
nutritionists, exercise experts and midwives
in close coordination with doctors to address
Indias health workorce shortages o qualied
clinicians. While this will require a change
in the mindset among many consumers to
accept new orms or caregivers, it will open
up a strong demand or new and dierent
categories o healthcare proessionals.
Chronic careToday, as the incidence o chronic illness
increases, chronic care management remains
expensive, labor intensive and plagued by
wide variations in the eectiveness o care.
In the win-win scenario, particularly among
the upper and middle classes, we believe
chronic patients, increasingly assisted by
health inomediaries, will be empowered
to take control o their diseases through
IT-enabled disease management programs
that improve outcomes and lower costs. Their
treatment will center on their location, thanks
to connected home monitoring devices,
which will automatically evaluate data and,
when needed, generate alerts and action
recommendations to patients and providers.
The poor will likely continue to struggle to
meet basic environmental needs and, thus, will
lack the inrastructure to substantially limit the
progression o chronic disease. Eorts to stem
chronic disease will necessarily be aimedat the inectious and liestyle contributors to
chronic conditions.
providers they choose, are likely to become
xtures in the healthcare landscape or both
the well and the chronically ill, as well as or a
much broader socioeconomic segment o the
population.
A current example o health inomediaries is
the National Rural Health Missions Accredited
Social Health Activists (ASHAs). There
are thousands o emale ASHA volunteers
positioned at the village level and trained in
preventive health. They promote sanitation
and hygiene, disseminate inormation on basic
preventive healthcare and acilitate access to
public health acilities, particularly or women
and children.
The care delivery transformationThe third key element in the win-win
transormation o healthcare is a undamental
shit in the nature, mode and means o care
delivery. Healthcare delivery is overly ocused
on episodic acute care; it should shit and
expand to include and embrace prevention
and chronic condition management in order
to respond to the emerging environment.
Preventive care
Today, preventive care, which ocuses
on keeping people well through disease
prevention, early detection and health
promotion, is a concept without a champion in
India. Generally speaking, consumers ignore
it, payers do not incent it and providers do not
prot rom it.
In the win-win scenario, we expect the
notion o preventive healthcare will expand,
combining allopathic and indigenous
approaches and the best o the old and the
new. Consumers are likely to seek this carein new settings, such as their workplaces
and homes, which should oer lower prices,
enhanced convenience and more eective
delivery channels than traditional healthcare
venues.
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5 Healthcare in India
Acute care
Today, acute care is the oundation o the
healthcare economy, and its eectiveness
depends heavily upon the expertise o the
individual doctor. In the win-win scenario, we
anticipate that standardized approaches toacute care, developed through the careul
analysis o clinical data and the unrelenting
documentation o patient variation, will be a
widespread starting point in care delivery.
The availability o high quality care inormation
should enable the treatment o non-urgent
acute conditions, such as strep throat and
sinusitis, at the patients home via the use o
telemedicine or at-work settings that provide
low cost, good quality and convenience.
This will ree doctor time and encouragethe transormation o todays massive,
general purpose hospitals into centers o
excellence devoted to specic conditions,
combination triage centers, which determine
the specialized acility patients should go to,
and post treatment recovery centers, in which
patients are monitored beore returning home.
And in poorer areas, care standards should
enhance the education o local providers. In
most situations, however, with the exception
o scarce mobile healthcare services, people
living in remote locations without basic
services will likely still rely on traditional means
o treating acute illness.
Toward a value-based and sustainable
healthcare system
The transormational challenge acing
Indias healthcare system is considerable
but addressable. It should expand its
primary ocus on oten poorly coordinated
episodic care to encompass the lie-long
and coordinated management o preventive,
acute and proactive chronic care across
Indias burgeoning middle class, as well as
or those who will not benet rom economic
development.
This expansion should be achieved with
limited incremental unding in an increasingly
competitive global economy and healthcare
environment. Successul transormation will
require all stakeholders to actively participate,
collaborate and change. But, correspondingly,we believe the rewards o successul
transormation are high or all stakeholders.
Successul healthcare transormation also
requires a shared vision and a comprehensive
long-term plan created through an open,
inclusive process. This seems obvious, but is
rarely done. Too oten, change is addressed
in a piecemeal ashion, and solutions are
generated by a ew experts working behind
closed doors. The result is systemic chaos and
minimal buy-in.
As a starting point or this discussion, we oer
a multiaceted vision or Indias healthcare
one that addresses the nancial, inrastructure
and proessional resource gaps that Indias
healthcare system may ace (see Figure 2). It
also requires key stakeholders to collaborate
in the renement o the vision and to dene
an explicit set o values or a desired uture
healthcare system.
FIGURE 2.
Proposed vision for Indias healthcare system.
Source: IBM Global Business Services and IBM Institute for
Business Value.
Sustainablecoststruct
ure
Alignedincentives
Tr
ansparency,
choice
Rationa
lcoverag
ede
ci
sions
Mu
tual
accountab
ility
Expe
rimentali
nnovationwithin
Robust
informa
ti
oninfras
tructu
re
anation
alframework
Consistent,evidence-based,high-value care
Wellness andprevention
Innovation,safety and
quality
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6 IBM Global Business Services
Healthcare in India paints a portrait o what the
Indias healthcare system can look like in the
next decade. Parts o the portrait already exist
in the country with notable advances in the
public and private sectors. Even so, bringing
the entire portrait to lie is an extraordinarily
diicult, but vitally important task, which must
be inormed and achieved through a process
o debate and consensus, and action and
accountability.
We invite you to read the ull report which is
available at
ibm.com/healthcare/hc2015
And we hope that our ideas will serve as a
starting point or the transormation eort.
AuthorsSrivathsan Aparajithan is the Head o
Healthcare Business Solutions or IBM India.
He can be reached at [email protected].
Shanthi Mathur is responsible or Healthcare
solutions delivery in IBM India/SA. She can bereached at [email protected].
Edgar L. Mounib is the Healthcare Lead or
the IBM Institute or Business Value. He can be
reached at [email protected].
Farhana Nakhooda is the Healthcare Solutions
Manager or the IBM Asia Paciic Public Sector
team. She can be reached at farhanan@
sg.ibm.com.
Aditya Pai is a Managing Consultant with the
IBM Healthcare and Lie Sciences practice
in Toronto, Canada. He can be contacted at
Libi Baskaran is a Senior Consultant with IBM
Strategy and Change and is member o the
IBM Institute or Business Value in India. He
can be contacted at [email protected]
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7 Healthcare in India
Related publicationAdams, Jim, Edgar L. Mounib, Aditya Pai,
Neil Stuart, Randy Thomas and Paige
Tomaszewicz. Healthcare 2015: Win-win or
lose-lose? IBM Institute or Business Value.
October 2006. Available at
ibm.com/healthcare/hc2015
About IBM Global Business ServicesWith business experts in more than 160
countries, IBM Global Business Services
provides clients with deep business process
and industry expertise across 17 industries,
using innovation to identiy, create and deliver
value aster. We draw on the ull breadth o IBM
capabilities, standing behind our advice to
help clients implement solutions designed to
deliver business outcomes with ar-reaching
impact and sustainable results.
References1
Ministry o Finance, Government o India.
Union budget 2007-2008. 2007; Central
Intelligence Agency. The World Factbook.
https://www.cia.gov/library/publications/
the-world-actbook/geos/in.html; NationalCommission on Macroeconomics and
Health. Burden o disease in India.
September 2005.
2National Commission on Macroeconomics
and Health. Burden o disease in India.
September 2005.
3Ibid.
4Adams, Jim, Edgar L. Mounib, Aditya Pai,
Neil Stuart, Randy Thomas and Paige
Tomaszewicz. Healthcare 2015: Win-win or
lose-lose? IBM Institute or Business Value.
October 2006. http://www.ibm.com/health-
care/hc2015
5Health literacy is a term used to describe
the capacity o consumers to obtain,
process, and understand basic inormation
and services needed to make appropriate
decisions regarding their health. (source:
IOM Committee on Health Literacy. 2004.
Health literacy: a prescription to end
conusion. National Academies o Science.
Washington, DC).
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