A couple of decades ago , a debate on the essence of medical
missions today would not have been necessary. Medical missions meant mission
hospitals which were mini townships, often in the middle of the wilderness, sometimes
standing with a school and almost always a church. Medical missions has a history
in India going back to the Colonial era because it is one of the earliest and
most visible manifestation of missions that was visible and still is visible to
the common man. It was widely promoted by the then government and can be understood
in my view as one of the earliest manifestations of public private partnership.
The state often leased out land to the Mission and provided facilities so that
drugs and equipment could be brought into the country and in return the missionaries
provided medical care with personnel that they brought in. the arrangement
worked well at a time when government provided medical care did not extend beyond
the big cities and hospitals were usually attached to medical colleges
or cantonments and in the princely states was dependent on the benevolence of
the Nawabs or Rajas in place. Three developments
challenged this cozy arrangement.
The first was the advent of independence and the foundation of
the welfare state where the State assumed the responsibility of providing
health care (among other facilities) to its citizens as part of the Nehruvian
vision. This meant the inauguration of the Primary Health care infrastructure throughout
the length and breadth of the country. How effective this vast mechanism was is
another question, but for the first time, outside the big towns and cities, a
systemic alternative to mission hospitals became available and mission
hospitals lost their monopoly. The quality of care at the PHC and associated
district hospitals might or might not be great, depending on who manned them
but an option to Mission Hospitals had emerged. Also post-independence, the
involvement of missions decreased over time as the symbiotic relationship with
the Colonial government and a natural chemistry was missing with the new post-independence
government. More on this later
The second big challenge happened in 1983 when Apollo
Hospitals opened up in the county and began corporatizing health care with the
clear aim of providing clinical services with an eye on the bottom line and
increasing shareholder value. The latter
did not necessarily make health care cheaper by default, but it did spark of
innovations in health care at the business model level and not just at the
clinical level. Till this time, health care in the private sector was at least
notionally nonprofit. Health care in the private sector was not usually cheap,
but the “profits” were usually ploughed back into the facility, to facilitate research,
improve infrastructure and so on. For the first time, a hospital was opening
whose sole reason to exist was to earn profits for its owners. Although there
were nay sayers, even in the pre-1991 pre liberalization era, the hospital came
to be and eventually spawned a whole range of corporate hospitals – big and
small. Now before the advent of the
corporate hospitals, there were the mission hospitals and there were a few large
nonprofits. Mission Hospitals would treat rich and poor alike and the rich had
few options at the time. Along the way, the rich would cross subsidize the poor
patients in the Mission hospitals but with the coming of Apollo and others
accompanied by aggressive marketing, the rich had more options to choose from.
The third was the entry into India of medical insurance. Although
less than 15 percent of India is insured, the entry of health insurance rewrote
all or many of the ways in which health care had been practiced hitherto. To
rationalize and reduce payments against premiums, treatment protocols began to
be rationalized, hospitals began to be graded and tie ups between insurance
companies and hospitals began to happen. As more and more insurance companies set up
shop, they brought in practices and norms that one had to adhere to or be
outside the mainstream medical system over time. A limited few medical hospitals adapted and
thrived , a lot many simply stayed put and gradually began to get obsolete. It is
then that the debate on revisiting medical missions perhaps really started –
when mission hospitals began to be
financially less and less viable and the question became very real – how else
could medical professionals live out the gospel if the only model in which it
had been practiced had become something that could not anymore be practiced ?
to be continued.........
