Trauma

International Perspectives

Fracture Treatment in the Indian Health Care System – October 2009

Dr Parag Sancheti MS. DNB. MCh.
Professor& Chairman
Sancheti Institute for Orthopaedics & Rehabilitation (S. I. O. R)
Consultant Orthopaedic Surgeon at SIOR
Visiting consultant at University of Dundee, U.K.

An analysis of fracture care in the Indian health care system would more than clearly show that even though the standard of care may be well defined, the ultimate decision for treatment involves other important factors such as cost, social, cultural and religious affiliations which the orthopaedic surgeon has to consider before deciding what would be the optimal treatment for his patient.

What makes India unique from other health care systems around the world is its large population and the equally large diversity in economic, cultural and religious values to which it caters.¹ India today is the second most populous country in the world and is expected to surpass China in 2030.² Adding to the burden of a large population is its equally wide cultural and religious divide. India can be broadly divided into its rural and urban populations and is traditionally a rural agrarian economy. Nearly three quarters of the population still live in rural areas and as of 2004 nearly 27.5 % of Indians were still living below the poverty line. Three hundred million Indians earn less than a dollar a day.³ While most of the rural population depend on primary health care centers set up by local government bodies, these centers are usually poorly staffed, have inadequate equipment, and serve more as referral centers for state central hospitals which provide free treatment for the poor. Urban area hospitals are well equipped with state of the art equipment and expertise; however, the cost involved in having treatment at these facilities makes it unattainable for all but the middle class and tourists.

Government run hospitals were the main providers of healthcare in Indian until the 1980's; however, over the last decade the Indian medical system has undergone a major change with an increasingly strong participation from the corporate and private sector. These private and corporate hospitals are highly advanced and provide world-class medical services. Corporate hospitals use the latest technology available and perform more complex procedures and treatments. Most state of the art equipment is imported from countries like the USA, UK, Germany, Japan etc. These hospitals have specialists for every department of medical care and employ doctors that are highly educated and have years of experience.

Dr Parag Sancheti with the team of surgeons and specialists at Sancheti Hospital The Indian Health care system is also unique in that apart from allopathic medicine, the health care sector is divided into other modalities of medicine including ayurvedic medicine, Unani medicine, homeopathic medicine, and other alternative medicines. Different sectors of the population have varied faiths in these alternative medical treatments. A considerable portion of the population still believes in the "local bone setters" for the management of trauma. Cultural aspects of the Indian population also have consequences that are unique to India rendering most validated scoring system defunct. By custom, most Indians sit cross-legged on the floor while eating their meals and praying to God, and the inability to do this post-operatively results in significant dissatisfaction with the treatment.

The Indian orthopaedic surgeon’s decisions also have to be cost effective as the health insurance sector in India has yet to develop and most patients pay from their savings. High quality medical care is available mainly to the upper and middle class, and tourists; however, in reality this sector constitutes only 25% of the total population. For the remaining population that cannot afford the standard treatment of care, the Indian orthopaedic surgeon has to use less expensive implants made by local companies and in some cases, older generation implants. Although this may be a deviation in the universal standard of care, the ultimate result in the hands of the experienced orthopaedic surgeon may not be much different using the more economical implants compared to international branded products. The need for good quality, less expensive implants is also reflected in the sprouting up of numerous Indian companies that produce international standard implants and sometimes make them available for 25% of the international cost. Some senior Indian orthopaedic surgeons have also taken the initiative in designing implants to suit Indian needs and make them available to the larger lower affording majority. Dr. K. H. Sancheti’s indigenous “Indus Knee” (high flexed knee replacement prosthesis) gave joint replacement surgery a new dimension by reducing the total cost of total knee replacement surgery to 500 US dollars. In view of long hospital durations, escalating costs of treatment, and concerns of affordability, orthopaedic surgeons are frequently dissuaded from heroic efforts in limb salvage in cases of mangled extremities and opt for amputation as an easy and more affordable option; in which case they commence their work at an earlier date with a suitable prosthesis instead.

The Indian population also has a wide diversity in its level of education and even today has a large percentage of illiterate people. As per the 2001 Census, the overall literacy rate in India is 65.38%. This also effects fracture management as patients may not follow the prescribed post-operative instructions; a fact which results in most surgeons being over protective, using longer periods of post-operative immobilization, and also being more careful with weight bearing after fracture fixation of a lower limb. These factors are also not considered in most validated scoring systems resulting in the depiction of poorer Indian outcome results.

The lack of an adequate emergency response system in the country has resulted in each individual center providing their own emergency response number which although effective, lacks the normal coordination seen in central based systems. This deficiency is responsible for the higher incidence of complications in fracture management with patients routinely presenting at delayed intervals due to lack of facilities in their rural habitat.

Today India is emerging as a hub for medical tourism which is one of the major external drivers for growth in the Indian health care sector. The availability of English speaking medical staff, state of the art private hospitals, diagnostic facilities, highly skilled/trained surgeons, and treatment at sometimes one-tenth the cost of international centers makes it a veritable destination for foreigners who have long wait times for their elective surgeries due to burgeoning demands on their own health care systems. According to a joint study by the Confederation of Indian Industry and Mckinsey, Indian medical tourism was estimated at $350 million in 2006 and has the potential to grow into a 2 billion dollar industry by 2012.

Today, Indian healthcare is also witness to numerous specialized hospitals equipped with state of the art equipment and expertise for dealing in specialties like orthopaedics, cardiology, nephrology etc. The Sancheti Institute for Orthopaedics and Rehabilitation, founded in 1972, has evolved into the largest purely orthopaedic center for south east Asia and acts as a tertiary referral care center receiving patients from all over India and other parts of the world including South Africa, United Kingdom, United States, the Middle East region, and parts of south east Asia. We are committed to following the highest level of ethical standards in patient care, clinical research, education, and administrative management. The institute offers 14 distinct specialist services that cover the entire spectrum of medical care in orthopaedics. Sancheti Institute is also an educational centre with affiliations to major medical colleges and establishments worldwide.

With the growing economy, a rising number of skilled surgeons, an increasing number of hospitals with state of the art facilities, diagnostic facilities, and the growing awareness of evidence based practice, the Indian health care industry is growing neck to neck with the software and pharmaceutical industry and will soon emerge as one of the leading health care centers in the world.

References

1. Indian census 1961: Office of the Registrar general and census commissioner of India
2. Health care in India: Emerging market report 2007: Pricewaterhouse Coopers
3. Finance wire, July 2006