[Excerpted from “Squeezing Out the Doctor,” The Economist, 2 June, 2012.]
Most countries suffer from a simple mismatch: the demand for health care is rising faster than the supply of doctors. The problem is most acute in the developing world, though rich countries are not immune (see article). It does not help that health care is notoriously inefficient. Whereas America’s overall labour productivity has increased by 1.8% annually for the past two decades, the figure for health care has declined by 0.6% each year, according to Robert Kocher of the Brookings Institution and Nikhil Sahni, until recently of Harvard University. But it is in poor countries that interest in alternative ways of training doctors and in alternatives to doctors themselves has produced the most innovation.
One approach to making doctors more efficient is to focus what they do. India is home to some of the world’s most exciting models along this line, argues Nicolaus Henke of McKinsey, who leads the consultancy’s work with health systems. Britain has 27.4 doctors for every 10,000 patients. India has just six. With so few doctors, it is changing the way it uses them.
Your correspondent recently watched Devi Shetty, chief executive of Narayana Hrudayalaya hospital in Bangalore, making careful incisions in a yellowed heart, pulling out clots that resembled tiny octopuses. It looked difficult. Some of the other tasks at Narayana Hrudayalaya hospital do not, and are not. Dr Shetty’s goal is to offer as many surgeries as possible, without compromising on quality. To do that, he ensures that his surgeons do only the most complex procedures; an army of other workers do everything else. The result is surgeries that cost less than $2,000 each, about one-fifteenth as much as a similar procedure in America.
The trick is repeated in other areas of health care. India’s LifeSpring hospitals slash the price of childbirth by augmenting doctors with less expensive midwives. The costs are about one-sixth of those in a private clinic. The Aravind Eye Care System offers surgery to about 350,000 patients a year. Operating rooms have at least two beds, so surgeons can swivel from one patient to the next. Most important, for every surgeon there are six “eye-care technicians”—young women recruited and trained by Aravind—who perform the myriad tasks in the operating room that do not require a surgeon’s training.
Other problems have inspired other solutions, with technology filling gaps in the labour force. The Bill and Melinda Gates Foundation supports a programme that uses mobile phones to deliver advice and reminders to pregnant women in Ghana. In December the foundation and Grand Challenges Canada, a non-profit organisation, announced $32m in grants for new mobile tools that will help health-care workers diagnose various ailments. In Mexico, worried patients can phone Medicall Home, a “telehealth” service. If a patient needs care, Medicall Home can help to arrange a doctor’s visit. But about two-thirds of patients’ concerns can be addressed over the phone by a doctor (often one only recently qualified).
These programmes are expanding. Medicall Home is rolling out its service in Colombia and plans to be operating in Peru by the end of the year. Aravind has exported its training model to about 30 developing countries. Dr Shetty already has 14 hospitals in India. He plans to add 30,000 hospital beds in big health complexes and small hospitals there over the next seven years, as well as build a hospital in the Cayman Islands.