In a candid discussion with Kinshuk Gupta, Dr. M C Misra, Director AIIMS scrutinises the reasons for poor healthcare structure in India and how we can have our way forward

Prof. M. C. MISRA

As you rightly mentioned, it is our 60th year of establishment, AIIMS came into being on 25th September, 1956 and it was established by Parliament as an institution of national importance. India gained independence in 1947, and we didn’t have any social of this kind and it was envisioned by the 1st Prime Minister of our country to have various institutions not only in medicine but in all fields. AIIMS was conceived with a principal objective of developing patterns of undergraduate and post graduate teaching and training of highest standards at par with anywhere else in the world. At that time, there was a deficiency of medical teachers in the country, it was also envisioned that this institute would produce medical teachers for the country, which it has over a period of time. Now, if we look back, we have created a mission which are patient care (which is also our strong USP and core strength), post graduate and post post graduate teaching and training, education, nursing, paramedic courses and research which have now become very important aspect of medical field. There have been various researches conducted here at AIIMS which has in turn helped the government of india formulate various national health programmes like national programme for prevention of blindness was initiated in 60s and 70s and after AIIMS was established, the first centre within AIIMS was the eye centre (Dr. Rajendra Prasad Centre for Ophthalmic Sciences). It was unique at that time, it is unique even today. And then, gradually, in the beginning we were a referral hospital, at that time if you look at India’s scenario for heathcare, it was largely nursing home driven care or public funded hospitals, medical colleges but that was government’s own responsibility towards primary care, secondary care. Ofcourse, this was envisaged as special care referral facility. But, over a period of time, it has become a multi speciality hospital of national repute and importance and a referral centre in those days when there were no corporate hospitals in the country. And, then in last 25 years since Escorts, gangaram, moolchand, tirathram hospitals were there but research was never an integral part of any of the private institutions and that is where AIIMS scored over these institutions always and it will keep doing that always in the future as well. If you look back, we started very small in 1956 with a very limited number of faculties of 80. Today, we stand tall with indoor bed strength for hospitals is 2500 beds in the main hospital and all the centres put together. Almost, 3.3 to 3.5 million patients visit our OPD department, out patient services, we admit more than 200000 patients every year and perform more than 150000 major operative proceduresacross specialities in the centres and then gradually concept evolve because of the need that the eye centre was the first centre within AIIMS as an independent centre under AIIMS umbrella with 300 bedded facility with all the eye disciplines. Then came about in early 1980s the concept of Neurosciences Centre encompassing all the Neurological and Neurosurgical Diseases, Cardio- Thoracic Sciences Centre encompassing Cardiology and Cardio-Thoracic surgery and then the Cancer Centre for which we also got some donation from the Rotary Club. Now, we have a Centre for Dental Education and Research within the campus, we have Jai Prakash Narayan Apex Trauma Centre, we have National Drug Dependence Treatment Centre where to deal with drug abuse and other psychiatric disorders in Ghaziabad, and Rural Centre in Ballabgarh. Now, we have 7 centres and main AIIMS hospital with a huge force of doctors of about 4000, 5000 nurses and an equal number of technical staff; almost 10000 workforce, in addition to that we also have the outsourced security services, cleaning services, other hospital services like central sterilisation department, kitchen services, laundry services, etc. Now, basically people’s expectation for healthcare has grown over a period of time, however, the resources have not grown in the same proportion. When corporate sector started showing up, we thought may be the importance of AIIMS like institutions would go down, but, today, I am happy to share that the significance of AIIMS and the likes have grown manifolds for a simple reason that in India 80 per cent of the tertiary or secondary healthcare is in the hands of private players. 20 per cent is in the public funded institutions. To add that, this 80 per cent private healthcare services can be accessed by maximum 20 per cent of the population which is also high, in fact, only less than 10 per cent of the public can afford the kind of expense involved, particularly, in the case of corporate care. You can imagine that this 20 per cent public supported healthcare is being competed for 80 per cent population and that is what puts strain at AIIMS and other such hospitals. The condition is such that Delhi hospitals are not only catering to Delhi patients but also to patients coming from other parts of the country. But, primarily, 55per cent of AIIMS’ patient population is outside Delhi. You can imagine what kind of volumes we are catering to which is a challenge as well as an opportunity for us. We are in the process of scaling up our services and the government is very supportive by providing us more funds because it is the responsibility of the Federal Government to ensure that we have enough funds to sustain this institution. We are also helping in capacity building in speciality and super speciality areas where we have increased in last 2 years since I have taken over here as a Director, almost 100 per cent seats in DM and M.Sc programmes. Overall, it is very satisfying to take up this challenge and do something for the country.

Government was planning to start 2 more AIIMS?
In 2004, the previous government under Mr. Vajpayee, and Ms. Sushma Swaraj was the health minister, they had announced 6 AIIMS like institutions. They were envisaged on the basis of the patient population coming to AIIMS. Conceptually, the present government has decided that pratically they will have an AIIMS or AIIMS like intitution in every state. The challenge will remain to man these facilties 24*7 with medical and paramedical manpower which is deficient, not only in India but global deficiency.

When we see mostly the private hospitals, in India it has become more of hospitality. Don’t you think private hospitals should come up and work hand in hand with government funded or public funded hospitals?
Every citizen has to contribute something towards the nation. You cannot say that 80 per cent of the population will come under MGNREGA or other schemes, and money will flow in. Everybody has to work towards productivity in the country. And, we have to do away from subsidies, gradually. We need to make people skilled enough to earn a decent livelihood, which is very important. Every country has a certain segment of population where somebody earns less and somebody earns more but, one should be able to access reasonable healthcare facilities where your needs are met. To establish a private hospital like Max or Fortis requires a lot of money, and they are not established with the motive of charity. They’re built up as a business model to earn profit on it. We cannot be blaming such hospitals for the plight of healthcare sector today. At the same time, we also need to strengthen the public funded healthcare system. Government also cannot shy away from its responsibility towards the health of its citizens. But, the point is how the government is going to fund this? Ideally, everybody should pay for their health but, if they cannot afford, then there should be a mechanism where government comes to their rescue, that’s how a reasonable healthcare can be provided. India is at an advantage where if we put preventive medicine upfront for people, like Swachha Bhaarat initiative by PM Mr. Modi, and we take it in the right spirit, it will reduce the infective diseases significantly. You don’t require treatment and expense on that. Similarly, if we drive safely on roads, you don’t require funding trauma team facilities. None of cancer hospitals in the West have incidences that we have here in India for example; India has 1/6th of breast cancer cases as compared to US or UK. Since, we are large in population so our numbers would also be large. But, we can create that facility where the patient can come at an early stage, diagnose, where treatment is possible, less expensive, patient suffers less and outcomes are excellent. What is happening is contrary that patients are coming late, diagnosed late, treatment becomes difficult and expensive, patient suffers more and the outcomes are compromised. Early detection of a disease is very necessary and providing corrective treatment in time. We need to spread awareness about various causes for life threatening diseases. It’s not that people will not get ill, but that number will be small. If everyone will pay 1re a day, 125cr people paying 1re a day that makes 125cr every day, imagine in just 12 months how much amount we can collect, which will be much higher than the cost that is incurred in the curative care annually and we can invest back in the healthcare industry. Insurance plays a vital and supportive role and should be bought at a younger age.

India is looked upon as a better medical facility provider and cost effective as compared to the west, but is India really looking into creating new age innovation and research of medicinal development?
Till now, we have been importing everything. Innovated outside, developed outside and we are simply using it. Like mobile phones, CT scan machine, ultrasound machine, MRI machine, even the metro coaches are imported from Germany, Korea and other countries. Innovation is not easy, but at least we can manufacture innovated items here in India but, we are not doing it. When we can make nuclear reactor and satellites and sustain them; then why not this? Innovation is not the culture here. But, now I am hopeful in the way Mr. Modi says, “Make in India”, he’s reminding us that it is important for the country. You cannot import every antibiotic, cardiac strength, implants, and other devices and most of our foreign exchange goes into either buying petroleum products or other such expensive products all in the name of health tourism. But, we fail to provide adequate facilities to our own people. Our allocation for funds on healthcare in India needs to improve if you compare it with the West, we are one of the lowest (4-5 per cent only) in spending on healthcare. On paper you will say, “food for all”, “education for all”, “health for all” but, in practice, it is not the case!

AIIMS has always been an epidome in quality research. How do you it growing and what kind of expenses have you been putting into such researches?
We have given trust by providing our younger faculty intra-neural research grants which was not available before 10 years ago, we also are the largest in research journal publication, though it may not match with same level institutions in US for a simple reason, that the faculty strength at AIIMS is 800 as compared to 3000 or more faculty members at any institution at the US. Also, their scale of funding is entirely at a different level. We are now doing quite better than before. We are also organising research methodology courses where we will teach how write research projects. We have fellows from all around the world, working together, emerse and work on needs. There is a lot of potential to be explored. Innovation and entrepreneurship is very important for the growth of the nation, but, that needs money. For example, if I have an innovation but I don’t find a venture capitalist to invest, then my product will fail.

Funding from government and private players plays a major role in the west. Why do you think someday this phenomenon will come to India as well?
Unless that happen, we will not be able to match the kind of research that takes place in the developed countries. It may happen in 10, 20, 50 or may be 100 years but, it has to come and the industry has to support research. They have to give people time for incubation. To make your dream realise, you need money and that’s how in the US a research goes to a logical conclusion. In India, I have an idea, I die with the idea because there is no one to take that idea forward. So, it has to come and the sooner it comes, it is better for the country. But, the government is trying to do it, at least in the field of biotechnology sciences they are doing it. I am hopeful, that soon it will expanded to other fields of engineering and the likes.