Primary Healthcare and the Emperor’s New Clothes

Healthinkers is a group of innovators and entrepreneurially minded individuals that meet once every 2 months to talk about the future of healthcare. We leave our professional obligations behind and focus solely on the challenges in creating a new healthcare experience for the future. In our last meeting on 1 September, we spoke about healthcare burden for the millennials, as they start bearing increasing costs for themselves, and their dependents over the next 2 decades.


Several challenges were discussed within our group — the rise in chronic care and mental health burden, the unlocking of latent demand from an explosion of online health information and the increasing cost of care, amongst many other issues. The one that we spent most time on was the lamentable state of primary healthcare.

It wouldn’t be an exaggeration to state that India has a non-existent primary healthcare system with resources loaded disproportionately at the top, in tertiary care interventions and in more urban areas. Many patients don’t feel the need to go to primary care doctors (referred to as GPs- general practitioners) in India. A simple google search for any symptom points patients to the specialist they think they need to manage symptoms. Consequently, endocrinologists manage routine diabetes and clinical cardiologists cater to routine hypertension and high cholesterol cases, conditions that should very effectively be managed by well-trained GPs. The use of highly trained medical specialists to manage what should be effectively managed by GPs is a sign that primary care is in very poor shape.

Despite it’s dismal state, the case for primary care is very strong. A recent issue of the Economist talked about the need to raise investments in primary care as a way to cost effectively manage healthcare burdens globally. Several studies have shown strong linkages between primary healthcare and better community health. Other studies have found that the least effective health systems have two common features — they allocate resources to a certain section or a particular type of intervention. Unfortunately, India’s healthcare system meets both those criteria. Our resources are disproportionately allocated to urban settings and to hospitals dedicated to acute interventions. Most Indians routinely seek out specialist care, the more degrees the better, not realizing that seeking a specialist is already a failure of the goals of healthcare. A specialist consultation should be a second or third order intervention (hence the terms secondary and tertiary care!) and we need all the specialists we have, and many more. But using doctors trained in specialties to provide first point of care makes no healthcare or economic sense.

This is a demand and a supply problem. Indians have never enjoyed access to credible primary care systems (unlike the UK) and so prefer to drive straight to one of many new clinics or hospitals for any healthcare need. Infrastructure is often mistaken for a surrogate for the quality of care they should get. The quality of care given to most patients at first point of access (unless it’s an emergency) is primarily influenced by the clinical expertise of the doctor, the size of the hospitals has no correlation with the care that can be provided. Many patients however, link the quality of care to these inadequate surrogates and are happy to pay extra out of pocket for the bells and whistles. Some people argue that accessing care at tertiary care centers allows easier escalation to higher quality care or referrals to specialists. This would be true except that most hospitals are terrible at care coordination and most specialists take a blinkered view of the condition or the organ they are treating (as they should since they are specialists). There seem to be no clear benefits for consumers to access specialists and hospitals for routine care, and yet they do!

Now here’s the supply side of the problem, the traditional family practice, in the charitable words of a colleague, is a dying profession. Doctors training in medical school can’t fathom the notion of being “just a GP” and many patients use the term GP dismissively. For doctors who do want to be GPs, the cost to set up a private clinic practice are very high. GPs make a fraction of the money made by their counterpart specialists that spent 3 more years in medical school. A simple calculation will show that a GP with a decent practice would probably take home less money than the starting salary of an MBA from a tier 2 school in India! In addition, GPs trained at the best medical schools often compete with all kinds of doctors and quacks trained in myriad kinds of medicine and schools. Patients are willing to walk down the road to the next specialist if the GP doesn’t make them feel better within 5 minutes. GPs can (unfortunately, many do) make more money from referrals to specialists, diagnostic labs and higher care. A model that offers financial incentives for doctors to prescribe more and a higher level of care may make sense to the individual doctor. However, this model make absolutely no sense to the patients or the total cost of healthcare.

GPs thrive on lifelong relationships for their business model to succeed and that’s also where their motivations lie. We also know longitudinal care of patients is best for long term healthcare outcomes. Yet, we haven’t found the right incentives to place our doctors in general practitioner roles that we know are best for our health. At a policy level, it’s trendy to talk about primary healthcare, but how many of us would encourage our kids to pursue general practice compared to a cooler sounding specialty (take your pick from cardiothoracic surgery, interventional cardiology, pediatric neurology). I’m betting 10 out of 10 would chose the latter.

There are other issues that compound the lack and quality of supply. Doctors pass out with skeletal training and are not ready to be high quality trusted general practitioners. Graduating doctors have very little formal communication skills, no understanding of chronic community care, no understanding of how to apply new medical research in the context of clinical practice and virtually no guidelines to manage patients. Freshly minted doctors are expected to pick up tricks of the trade, to be businessmen- responsible for financing their clinics, managing licenses, hiring support staff, negotiating prices for equipment, figuring out ways to market themselves, get enough patients, build a reputation and make enough money, all the time planning to not send their kids to medical school!

Talk of doctors with many of my friends usually evokes a common response — they make too much money (and many of them do make good money)! For some reason, we can’t digest that, it’s cool for bankers, entrepreneurs, politicians, and even Godmen to make money, but doctors are condemned to a lifetime of servitude and any money they make is already too much. Many enterprising doctors have been able to work around these clichés. General practitioners unfortunately, haven’t been able to.

There is a need for us to raise the profile of GPs and primary healthcare. I’ve seen some excellent GPs and primary care practices that are trying to structure and systematize their care. Our primary care physicians need to be better trained, supported and we need to be able to demand more from them. But to do that, we must recognize the signs and resurrect this dying profession first. We need to find financial models that work for GPs and patients and leverage technologies that can elevate the quality of primary healthcare in the communities.

Healthinkers spoke a lot about millennials being a health-conscious generation. I hope this turns out to be true. And I hope that the increasing focus on healthier lifestyles as well as steeply escalating healthcare costs will drive us towards developing a robust primary care ecosystem. We have to wake up to the perils of the path we are heading on. Let’s put some clothes back on the Emperor.

Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the CEO of Avegen and lives in Mumbai, India.


Originally published at Connected Health Quarterly.