Tuesday, December 2, 2014

Medical Missions in today's time and age ...........


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.........