SAS Health Care on quacks killing patients and poor governance

Somewhere in the mid-2000s, a young Arjun Sachidanand was interning at a hospital in a poor locality. “I come from a family of doctors. My father was already operating, and I was assisting him that day. But a patient who’d come in was in bad condition, so dad asked me to go down, as he was already scrubbed.” What Arjun saw was a young girl, not more than three years old, frothing at the mouth and half unconscious. She was immediately moved to the intensive care unit (ICU). Her parents were questioned: “How did this happen?”

More than seven weeks before that day, the same couple had come in with their feverish daughter. The doctors, then, prescribed antibiotics, and charged Rs 100 for consultation. A throwaway amount for many of us, but poor as the couple were, after having paid their consultation fees, they didn’t have enough left to buy medicines from the pharmacy. So they left.

“They went to a local quack,” says Arjun. “The area where I was working was a poor one, so there were a lot of quacks around. He actually turned out to be a sweeper from Bangalore Medical College. He gave her two injections and charged Rs 20 for them, which made the fever go down.” Those two injections were doses of Betnesol, a steroid that masked the fever, and Diclofenac, a nonsteroidal anti-inflammatory and analgesic. Once she was too sick for him to handle, he asked the girl’s parents to take her back to the hospital. “Because of Betnesol being given so many times, her immunity had reduced. Eventually, infections were able to pass through her blood-brain barrier.” It took a whole week for her parents to gather enough money for a second consultation.

It was too late. Within half an hour of entering the hospital, she died of meningitis. Had the parents been able to afford the antibiotics this wouldn’t have happened. Had there been better regulation to weed out India’s millions of quacks, this wouldn’t have happened either. “I didn’t want to pursue medicine anymore. I went and did my MBA in Hospital Management, instead. I wanted to present a model where people benefitted out of hospitals. When we first started, there was no RSBY (Rashtriya Swasthya Bima Yojana), no proper government scheme running to cater to the poor. In 2009, we set up a company, SAS Poorna Arogya Healthcare, and started with 500 clients in Uttar Karnataka. Once membership grew, we set up a 30-bed hospital in Mysore called Kaveri. Now, we have three lakh clients; World Bank recognised us and gave us a grant to expand in Assam.”

Arjun’s anecdotes are telling and very reflective of India’s healthcare jam. As of 2012, we spent a paltry 4.1 per cent of our GDP on healthcare. This in a country of 1.6 billion -mostly poor- people. The same year, World Bank data shows that for 1,000 patients, India is able to provide only 0.7 doctors. By comparison, Cuba has 6.7, China has 1.9, Bangladesh has 0.4 and Pakistan has 0.8. Even bed density increase over the last 10 years -70 per cent of it- has been largely due to the influx of private healthcare centres. A 2012 McKinsey report claims that, based on health indicators, India will fall short of its 2015 MDG targets. In fact, between 2000 and 2010, our healthcare expenditure dropped from 4.4 to 4.0. There never has been fast, consistent growth, only a sluggish back and forth. Our share of hospital beds (63 per cent), doctor density (0.7:1000) and insurance coverage (25 per cent) in 2010 was the same as Brazil, South Korea and Thailand in 1965, all of whom provide far better healthcare services to their people now.

It’s not just the patients suffering, though. Doctors are overworked. Two weeks ago, #YoTambienMeDormi (I’ve also fallen asleep) trended on Twitter, in Mexico, after healthcare staff protested long working hours. The situation is similar in India, too. Corruption, lack of regulation and poor quality of healthcare services in the country has created a deep sense of hostility and suspicion in the public, where bad news is, now, always equated with ‘bad work,’ especially if you’re a junior doctor or intern. In just two decades, thousands of doctors have been attacked, abused or even killed by rampaging relatives or even hare-brained party members. India, simply speaking, is a bad place to be a doctor or a patient.

The root problem with India’s healthcare system, according to Arjun, is its inability to properly implement its many schemes and regulate. “In the village, a person falls sick. He goes to an overworked government hospital, where he has to bribe everyone from the peon to the nurse just to see the doctor, who’ll have no supply of medicines. All he does is give the patient contact details from where he can get them.” The irony is that government hospitals aren’t jerry-built medical centres. Their infrastructure rivals delux hospitals, yet service delivery is shoddy. It’s no secret that the quality of doctors available to the poor is equally poor. On the other hand, Arjun says, “In private hospitals, as soon as you show an insurance card, the cost goes up. They have a tendency of admitting patients for no reason. The government definitely has a major role to play in streamlining its own systems. Even the RSBY programme is very nice, but implementation is the issue. So many people who have the card don’t know what the hell it is. We have to tell them it’s an insurance card, because they’ve been using it as a photo ID. We need more public-private partnernships to educate people.”

SAS Health was initially supposed to be a programme that helped the poor access healthcare. However, not every hospital Arjun approached was comfortable with charitable projects; others didn’t have the infrastructure. He realised that providing 200 million impoverished Indians healthcare would be an insurmountable task if he didn’t build his own infrastructure. “Now, we’re in the process of setting up 10 hospitals, which will be operational next year. They’re all 30-bed hospitals, with an OT, an ICU that can cater to five patients and a pathology lab, which we’ll outsource. We’re also setting up our own pharmacies to bring in generic drugs that’ll cut costs for patients.” To break even, every hospital comes with a restaurant that’ll cater to patients and outsiders. “We’ve already done that in some of our centres, with subsidised prices for patients.”

When Arjun first began thinking of expanding beyond Karnataka, his first thought was to move into adjacent South Indian states. But SAS Health came across a World Bank initiative that sought to provide support to healthcare centres looking to establish in North-East India. “For the initial set up, dad provided a lot of capital support. When we wanted to move outside, the cost was too high. We were not ready for equity, because we’d not scaled that much.” That’s why Arjun chose Assam. Not only would the World Bank assist his expansion, but the North-East is notorious for having a mix of standard medical infrastructure, but hopelessly poor medical services. It seemed like a good market to improve.

Still, there is a deep sense of mistrust the general population has against the healthcare industry. A criticism levied against it is that it’s run like a ruthless money-minting machine, where only the rich can afford to fall sick. “There are a lot of pharma companies lobbying for generic drugs to not come into the market.” Essentially, both drugs are monitored, regulated and licenced by the DCGI. Arjun continues, “The efficacy of the drug is not under question. It’s the availability. Ciprofloxacin, which is marketed under a label , goes through distributors. By the time it reaches the patient, everyone makes money. So it’s the pharma companies that aren’t letting generic alternatives into the market directly. This problem is there in every aspect of healthcare. If I’m operating a fractured femur in Mysore, and I need an implant, I can bargain with distributors to get the implant for Rs 3,000 to Rs 5,000. In Assam, the same implant will not cost less than Rs 30,000. The only way to stop this is if the medical fraternity asks to be regulated.”

It’s neither new for pharmaceutical companies to, in essence, ‘buy’ doctors with promises of commissions and lucrative deals (to market their products). A hospital may prescribe a more expensive alternative of a cheap drug due to deals it feels it has to make with pharmaceutical companies. “It happens day in and day out,” says Arjun. “They’ll say, ‘Buy 100 vials, and we’ll give you 100 free.'”

For SAS Health, the biggest challenge comes from expansion. From a staff of four to 250, language barriers becomes a major hindrance. Handling logistics when moving from one city to another, let alone a whole new state, is a difficult undertaking. “Now that we’ve set up our own chain, other hospitals don’t want us to give our services at the rates we do. It directly impacts their business. Every time we set up a hospital, neighbouring ones will regulate their rates looking at our programmes. So scaling and pricing problems always come into question.”

Arjun says SAS Health has a network of 108 hospitals in Karnataka and 17 in Assam. They try their best to collaborate with hospitals that are more inclined towards the traditional principles of medical care and ethics. There are even plans to expand into Nigeria and Kenya, where the local governments have asked for assistance to develop healthcare programmes for their poor. “At SAS, we’re looking at big numbers. We don’t want to operate on 10 patients a month and collect complete turnover costs from them. We’re looking at doing 100 surgeries a month. Patients will come if you give good services – if you’re compassionate. In a span of three years, in Mysore, we’re performing more surgeries than bigger hospitals. Doctors should take it slow. There’s no need to start profiting in the first year itself. These things take time. The important thing is to care for the patient. There’s word of mouth, and God will do His bit. ”

“We don’t need to make any compromises. Healthcare has to have a social component. Even though it’s an expensive venture, that’s the whole point of becoming a doctor or setting up a hospital. You can still lead a normal life; you don’t need to lead a flamboyant, luxurious one. In my opinion, no compromise in the service delivery or pricing should ever be made.”