NEW DELHI, India — Rakesh Kumar sits patiently in the waiting area of a government hospital in the northern Indian state of Haryana. His brother is undergoing a CT scan after sustaining a head injury.
Kumar had originally taken his brother to a private hospital for the scan, but it was too costly and the wait was several hours long. But here at a government-run hospital in Gurgaon, a city known as India’s financial and technology hub, the wait was just a few minutes and the price was a fraction of the cost of seeking care in the private sector.
Health system challenges
The biggest challenge for India’s health care system is to provide care that’s affordable and accessible to its population of 1.3 billion people, almost 70 percent of whom live in rural areas.
Public health care institutions — ranging from primary health centers that form the backbone of the system in rural areas to larger district-level hospitals — are hampered by a lack of manpower and inadequate resources such as diagnostics, pathology services and stock-outs. As a result, most people rely on the private sector for health care, which provides almost 80 percent of outpatient and 60 percent of inpatient care.
India’s 2017 National Health Policy emphasizes the role of the private sector in helping the country achieve its aim of Universal Health Coverage. The government advocates for the “strategic purchasing” of care from private facilities and clinics to improve access, affordability and quality of care.
While the policy envisions private investment in areas where there are few, if any, providers, some experts have questioned whether government funds would be enough to incentivize health companies to expand into rural areas.
While Haryana — a state of 28 million people — has basic radiology technologies available including x-rays and ultrasounds, high-end diagnostic tools such as MRIs and CT scans aren’t available in the rural areas where the vast majority of the state’s population live.
Another challenge is the lack of radiologists. According to Dr. Maneesh Rathee, medical superintendent of Gurgaon’s Civil Hospital, there are only five radiologists working in the public sector across Haryana. Many of them are driven to the private sector, where they earn higher salaries and can operate in better working conditions.
While MRIs and CT scans are available in Gurgaon — predominantly through the private sector — such facilities are out of reach for most people.
Private sector engagement
In response to the lack of accessible and affordable diagnostic services, the government of Haryana tended a 10-year contract with HealthMaP Diagnostic Private Limited, a joint venture between Manipal Health and Philips, to develop and maintain a network of advanced radiology diagnostics services across nine sites in the state.
The business model is a public-private partnership where the government provides the physical space at hospitals while Philips provides the technology — the MRI and CT machines — and HealthMaP the end-to-end services including their own doctors and technical staff.
The PPP at Gurgaon Civil Hospital, a bustling hospital with 1,500 outpatients per day, has been running for 22 months. In that time it has performed 12,000 CT scans, the Chief Executive Officer of HealthMaP Niraj Arora told Devex in an interview.
Across the nine sites in the state where they operate, 150,000 MRI and CT scans have been completed in almost two years.
HealthMaP also runs a PPP in Jharkhand, a state in north-east India fraught by a lack of medical infrastructure and high levels of poverty. In Jharkhand, the company runs advanced radiology and pathology diagnostic services at seven sites under the same model. By March of 2018, eight new sites are slated to be added in Jharkhand and three in Haryana.
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In Gurgaon, HealthMaP employs 11 staff including one radiologist and three technicians; the company employs a total of 15 radiologists across the state.
“We’re looking at delivering high-end imaging to patients who can’t afford it and who, without us, will never get that scan,” said Arora.
Pranav Chandna, head of Philips Capital India, said the goal is to provide access to as many people as possible using technology in an innovative way.
“It’s not that the government can’t afford the technology by themselves … it’s about [whether] you’re able to provide services back to the patients,” said Chandna, explaining that it was essential to be able to manage the equipment purchased, and use the technology to its full advantage.
“The critical question is: how fast can we reach there? That’s [what] we’re trying to answer. A PPP is a way of helping us reach there faster.”
Utilizing technology
The base rate of a scan under the PPP model is 660 rupees (the equivalent of $10) — 35 percent of the going rate in the market.
But for patients who live below the poverty line, are already burdened with other health expenses or simply can’t afford it, the service is free.
Once a person undergoes a CT scan after being referred by a doctor, the turnaround time is quick: if it’s an emergency, the patient will have the results within two hours. If it’s not time critical, the results will be available the following day at whatever location the patient wants. Up to 80 percent of the patients who require care receive it at the hospital.
Prior to the PPP being operational, patients requiring a CT scan were referred outside the hospital, which often resulted in a loss of follow-up because patients couldn’t afford to seek care in the private sector. Now diagnostics and treatment are under the same roof.
Technology enables all nine centers in Haryana to be linked to a centralized hub where diagnostic images are pooled into one server that is also available offline.
That means if a radiologist is unavailable or not present at the site, another can examine the scan and report back immediately, regardless of where the patient is located. The pooling of technology and manpower to a common spot also means that the best radiologists don’t need to be in remote places.
“While we sit in a bigger city today, there are smaller towns where getting a good radiologist is difficult. But we are able to provide them the same services and same standards that we are managing here,” said Chandna.
“Technology helps get access to patients even if the number of skilled manpower continues to be limited. The government is able to use this as a tool to get into deeper pockets where even primary health care is a big concern.”
Overcoming challenges
Arora acknowledged that assessing the sustainability of a PPP requires patience and time. He said that the ability to pool radiologists together to help one another in cases of overflow and unavailability, in addition to frequently examining cost efficiencies to achieve sustainability, are good indicators the PPP is on the right track.
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The biggest challenge for the project has been to provide services at the lowest possible cost. Chandna said he sees potential to reach more patients beyond the 25 to 30 they currently reach per day in Gurgaon.
Arora agreed, noting that HealthMaP hasn’t invested much in marketing activities to reach more patients, relying instead on physician referrals.
“We need to get the message out,” Chandna added.
The technology revolution
Dr. S.B. Gandhi, a radiologist with HealthMaP in Gurgaon, said that technology has drastically improved the resolution of the scan, allowing him to interpret results in a quicker and more resolute way.
“We now can work from a remote area and around the clock,” he said.
“The majority of patients I meet feel that HealthMaP is reliable. That’s the trust we’ve created in the last two years and that’s a great achievement for the future of health care in India.”
Looking ahead, Chandna sees PPPs gaining more momentum in India. He predicts an increasing number of in-house hospital departments such as cardiology, oncology and surgery working under PPPs rather than a reliance on either the overburdened public sector or the expensive private one.
“Clearly a path has been created where the government and the private sector can partner,” he said. “You can really translate that and start giving access to more people both on diagnostics and on the other side of the health care spectrum.”
But only time will tell whether PPPs will be able to reach all the pockets of India’s burgeoning population and challenging terrain.
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About the author
Sophie Bader
Sophie Bader is a journalist covering global health based in South Asia. She recently completed a master's of public health and writes frequently for The Lancet and The Guardian.