Year : 2012 | Volume
: 56 | Issue : 2 | Page : 105--109
The medical mandala: The public health benefits of entrepreneurship tools and skills among medical students in India
Freelance Consultant, Prins Hendrikkade 160B, 1011TB Amsterdam, The Netherlands
Freelance Consultant, Prins Hendrikkade 160B, 1011TB Amsterdam
|How to cite this article:|
Rhodes G. The medical mandala: The public health benefits of entrepreneurship tools and skills among medical students in India.Indian J Public Health 2012;56:105-109
|How to cite this URL:|
Rhodes G. The medical mandala: The public health benefits of entrepreneurship tools and skills among medical students in India. Indian J Public Health [serial online] 2012 [cited 2020 Oct 27 ];56:105-109
Available from: https://www.ijph.in/text.asp?2012/56/2/105/99899
During a recent executive summer course on issues related to Public Finance Management (PFM) for public health system managers at the Royal Tropical Institute in Amsterdam, it was suggested to me that such training might be useful to medical students. Discussions soon led, however, to a more radical proposition: a proposition put to you here.
Provide medical students not with health economics and public finance training and tools, but with the enterprise skills and software to manage their private practices successfully, and the seeds could be planted for a 21 st century answer to the public health systems of the 19 th and 20 th century; a Public Health Mesh. A 'social medicine' system fit for the information age.
This paper proposes that the Internet provides both the means and the architecture to create a radical alternative to the traditional public health system. It is proposed that by moving from an 'hierarchical network system' to a 'decentralized network system', not only would what is now widely seen as the greatest weakness of the public health system in India, and indeed elsewhere, be transformed into its greatest strength - the irrepressible entrepreneurial spirit of Indian medical professionals - but also, the vexed relationship between public health and public finance authorities could be brought into a new and more constructive era of sector governance.
In the first section, a brief history of that relationship between public health and public finance policy and policymaking is presented. In the second, how changing health system architecture could go some way toward ameliorating the inevitable tensions between system 'equity' and 'efficiency'. Finally, it is proposed that to achieve this, we do not need a grand and expensive plan, but rather, we should focus on the other end of the scale, where this proposal to some extent started, with humble medical students - and the future generations of a constantly evolving medical mandala.
A Short History of Welfare Finance, Health Economics, and Public Health
In 1985, Alan Williams produced a seminal paper in modern health economics.  The paper introduced QALYs, and the idea that 'health outcomes' could not only be measured comparably across interventions, an earlier idea, but also that public authorities could use this information to prioritize public spending on health care transparently and 'rationally'. , Why was this so interesting? Simply stated, because then, as now, public finances in his country were under considerable strain. Why target health care? Because then as now, the UK ran the health care industry as a single hierarchal (referral) 'integrated public health system' financed through general taxation. The iconic National Health Service (NHS) was simply the largest item on the public books. The dangers of this concentration both for public health and public finances had been clear for many years.  They persist.
What was true at the time in the UK, and across the OECD, was also happening in developing countries - and to and through development aid budgets. This was the era of 'structural adjustment' and the vilified Washington consensus.  Health care in developing countries was hit hard because it was also just a very large component of sovereign public finances. Shared policy approaches a common legacy of colonialism. 
For those who view (ed) health care primarily in moral and legalistic terms as a 'human right', relief for integrated public health systems from the assaults of public finance economists had to wait until economic recovery in the 1990s and the Millennium.  As the cold war thawed and the world went 'mobile' and 'on-line', public finances around the world similarly recovered.  Ironically, the very tools and theories that had been developed to implement rationing could now be used to justify inevitably concomitant increases in public expenditures. , Health economics and outcomes research expanded from a cottage to a global industry. , Anyone looking for their new product or program to be included in 'the health system' - and hence enjoy the security of public reimbursement - developed a measure of its unique 'performance' and 'impact'. The essence of QALYs and rational priority setting to maximize public expenditure performance (and contain risk and public expenditure) was largely lost under avalanches of heavily (socially) marketed alternatives on the 'market access' supply side and the ever-expanding Health Technology Assessment (HTA) requirements and bureaucracies on the other (by definition, collective), demand, side. Health economics became a standard component of public health programs (TropEd.org).
Could the same (marketing) strategy, and public health and rights-based perspectives on public finance, not be applied to health system strengthening globally?  Williams, and the economics old school, fumed at the idea.  But the Macro-economic Commission on Health published 'evidence based' findings that same year to great fanfare.  An unprecedented increase in multilateral resources for global public health followed.  But, as is now becoming clear, this growth is not linked to public health care budgets, administrations, or (directly) networks, but, largely, to the foreign affairs budgets of a few UN members, that is, sovereign discretionary spending in the analytical terms of the economics old school. Those components of sovereign public finances that best practice typically dictate adjust automatically to stabilize the ship of state in times of fiscal pressure. In times of enduring fiscal crisis, the continuing influence on sovereign health care policy of the 'global health community' must be considered far from automatic. 
In India, the numbers of the global health community approaches never added up. A federal country with a growing and increasingly sophisticated population of more than 1.2 billion people, public policymakers in health and health care had to remain more sanguine over the past decade and have explored their own solutions. , On the one hand, these solutions reflect the continuing consensus in international public health, since Alma Ata. On the other hand, they reflect the evolving solutions for the sector beyond 'primary care' - particularly in terms of (demand side) insurance market developments and public-private mixes in medical services supply, thus, converging with the sovereign public finance policies and realities in developed, emerging, and developing countries alike. No state can afford the universal and comprehensive coverage of modern, increasingly capital-intensive medicine. 
Debate has therefore come full circle since Cochrane. The original challenges of Williams and his colleagues remain: 'How can we set priorities in health care and other "merit good" services to be funded under sovereign public finance?' and 'What is the correct "public-private mix" in health care services and insurance?' 
It is possible that the cycle of pitched policy battles between those protecting the public health and those protecting the public finances, between 'equity' and 'efficiency' in health care, will be repeated again along familiar lines. Although something fundamental has now changed: the internet and information and communication technology (ICT). The dawn of the information age, in which India is already leading in exploring low-cost, high-impact innovations in, for example, social welfare administration, creates an alternative 'systems' approach, which could transform both debate and system performance -in terms of both the public finances and public health.
Network Topology and the Architecture of Sector Governance
The interminable policy debates between 'efficiency' (fiscal responsibility) and 'equity' (patient rights and entitlements) in 'health systems' are so pervasive that it is difficult, even heretical, to imagine that they might be framed any other way. Although it is the differences between health professionals, rather than public health and public finance officials, that provide perhaps the key to breaking the cycle. In particular, the growing tensions between the objectives of the practitioners of medicine and public health (increasingly differentiated into 'social medicine' and 'general practice medicine' worldwide) can no longer be ignored. The information age may provide the means, architecture, and language to completely transform and re-frame all three fields. And India could lead the way.
In India, unlike in the UK, a graduate leaving medical school and going into general medical practice is unlikely to work in public services or desire to. Despite the flagship National Rural Health Mission, total private sector expenditure accounted for more than an estimated 71% of total health care spending in India in 2008-09.  Private sector estimates put the proportion even higher.  A rapidly growing economy, advances in medical technology (reducing also supplier prices and investment costs), and growing consumer information and assertiveness mean that medical practitioners can focus unrepentantly on their priority: individual patient care.
This leaves public health authorities at the state, federal, and indeed international level with a problem. Their focus is not individual patients, but populations. From this perspective, the 'integrated health system' is not only (or even primarily) a means of extending medical services to a population - a small explanatory variable of population health in any case - it is an instrument for collecting and disseminating (public) health information. An organizational and control system designed when information was shared on pieces of paper, and by states with the centralized means to project the 'soft power' of human resource intensive, but technologically limited, medicine - free to all. Interestingly, the increasingly divergent perspectives and interests of medicine and traditional international public health have direct analogies in (information) systems theory.
Systems theory, the study of networks, distinguishes two broad groups of network topologies: hierarchical systems (e.g., network 'trees') and decentralized systems (e.g., network 'stars' and 'meshes'). The traditional (Western) 'public (social or integrated) health system' is an example of a centralized hierarchical network. In a hierarchical network, each 'node' (individual or organization) in a system has single point-to-point connections, for example, the tiered referral system in an integrated health system. However, because medical professionals in emerging markets such as India are dependent on much more pluralized (public and private) and individual and collective (insurance) sources of funding to survive, individual physicians and medical organizations (system 'nodes') have no central authority and multiple connections. They form decentralized system 'meshed' networks.
Both systems have advantages and disadvantages. Hierarchical (centralized) networks may be more 'efficient' at the collective level and provide considerable control to a central authority, but the collective (central) means to build and maintain them must also be available. Decentralized networks, on the other hand, are more expensive and difficult to set up, but they are also more robust and secure. Failure at a central hub will not collapse the system nor, crucially, does the expense of building or improving the system fall on to one central party. Making it also the organizational structure of choice for those interested in 'governance without government'. 
There are, in fact, only two major requirements to make such a network work: an interest and willingness to participate among nodes who are otherwise self-interested, financing, and sustaining and an information exchange protocol or 'language' (technical and procedural discourse) that shares some common architecture. As we are talking about people and not computers, yet, this means access to a common education platform. Coincidentally, medical education is the one part of physician's life in India that is still largely dependent on public institutions.
A Future for Business Economics in Medicine
Unlike in postgraduate training in public health (in terms, therefore, of social medicine), it is very unusual for a physician to receive any training in any aspect of welfare economics and finance. This knowledge, with its similarly public and 'collective' focus, will also not help them 'mobilize resources' as it has their colleagues managing public health systems, enterprise economics and finance, on the contrary, with its focus on individual organizations, maybe useful to them. (Social) enterprise and practice management skills are therefore likely to be of much greater interest and relevance. Is it conceivable that, by giving physicians the tools to 'take care of business', a public health mesh could be created to do a great service to medical practice, social medicine, and public finance and welfare economics alike ?
In business economics and finance terminology, most medical private practices are small and medium-sized enterprises (SMEs). SMEs can be run on a laptop and one or two small business packages. One does not need a Master of Public Health or Business Administration. The focus is the interest of the company or practice and its owner (and, increasingly, the privacy of 'client' data that may be stored). What would be the result if even the minimum amount of health data fields on these laptops could be connected? Could a (Public) Health Mesh eventually replace a (Public) Health System?
Integrated health care systems have been the crucible for some of the most spectacular and expensive failures in the public procurement and administration of IT projects over the past two decades.  Nothing therefore can be guaranteed and considerable feasibility analyses, both technical and financial-economic, would be required before launching even exploratory projects to answer this question. Nevertheless, keeping in mind the key characteristics of meshed networks, it is not difficult to imagine that by embracing organizational evolutions in health care in India, and accepting private practice, public health and social medicine goals could be pursued simultaneously. Two golden rules:
The nodes drive and sustain the mesh. Like 'Facebook', the stronger, more independent, and greater the number joining, the more valuable the mesh. Everything, starting at the interface, must be designed to maximize the interest and acceptance of otherwise voluntary self-governing practices (system nodes);Any mesh architect will need to rank and prioritize information and language it would like to see shared. Compromise the interests of the nodes and the mesh will be compromised, therefore, for example:
(Infectious) disease reporting and eventually even alarms would not seem to conflict with Rule 1 and may even be useful to promote 'social enterprise' credentials of a practice;Treatment information and reporting is both medically and commercially valuable and is likely to become more so - how can Rules 1 and 2 remain compatible across different areas and levels of information sharing and phases of mesh evolution?Absolute discretion over client and financial data are the defining characteristics and inner sanctum of private practice (Rule 1). System architects both now and in the future would probably be wise not to lose sight of this fact.
Start humbly, with little more than better-qualified crowd sourcing (e.g., healthmap.org) and evolutions and system dynamics could take a Public Health Mesh where health systems strengthening will not bring public health in the 21 st century. 
The Public Health Mesh: A Medical Mandala
It is not difficult to imagine a near future in which medical students in India leave college with a medical bag under one arm, and a laptop office under the other.
Serve, respect, and even promote their personal practices and interests - and those of their future patients and clients - and there is no reason to assume that successive generations will not be happy to join them in sharing those small number of data fields on those laptops that, when aggregated, could be of great and even vital strategic public (social medicine and epidemiological) interest. India may not need a 20 th -century public health system; it could develop the world's first 21 st -century public health mesh.
I would particularly like to acknowledge and thank Prof. (Dr.) Atul Kotwal and Prof. (Dr.) Sanjay Zodpey for their contributions to the discussions that made this paper possible.
|1||Williams A. Economics of coronary artery bypass grafting. Br Med J (Clin Res Ed) 1985;291:326-9.|
|2||Rosser RM, Watts VC. The measurement of hospital output. Int J Epidemiol 1972;1:361-8.|
|3||Culyer AJ. Cost containment in Europe. York: Center for Health Economics (York University) Discussion Paper 62; 1989.|
|4||Cochrane A. Archie Cochrane in his own words. Selections arranged from his 1972 introduction to "Effectiveness and Efficiency: Random Reflections on the Health Services" 1972. Control Clin Trials 1989;10:428-33.|
|5||Williamson J, (editor) Latin American Readjustment: How Much has Happened. Washington: Institute for International Economics; 1989.|
|6||Lewis J. Empire State-Building. Ohio: Ohio University Press; 2000.|
|7||Yusuf S. Development Economics through the decades A critical look at 30 years of the WDR. Washington: World Bank; 2009.|
|8||Varian H. Economics of Information Technology. Berkeley: University of California; 2003.|
|9||Newhouse J. Medical Care Expenditure: A cross-national survey. J Hum Resour 1977;12:115-25.|
|10||World Bank. World Development Report 1993: Investing in Health. Washington: World Bank; 1993.|
|11||Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973;182:1102-8.|
|12||Drummond M, Brown R, Fendrick A, Fullerton P, Neumann P, Taylor R, et al. Use of Pharmacoeconomics Information-Report of the ISPOR Task Force on Use of Pharmacoeconomic/Health Economic Information in Health-Care Decision Making. Value in Health 2003;6(4):407-16.|
|13||WHO. World Health Report 2000: Heath Systems - Improving Performance. Geneva: World Health Organisation; 2000.|
|14||Williams A. Science or marketing at WHO? Rejoinder from Alan Williams. Health Econ 2001;10:283-5.|
|15||WHO. Investing in Health for Economic Development: Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization; 2001.|
|16||IMHE. Financing Global Health: Continued Growth as MDG Deadline Approaches. Seattle: Institute of Health Metrics, University of Washington; 2011.|
|17||Global Fund. The Global Fund adopts new strategy to save 10 million lives. (Press Release on cancellation Global Fund Round 11). Geneva: Global Fund; 2011.|
|18||Duggal R. Healthcare in India: Changing the Financing Strategy. Soc Policy Adm 2007;41:386-94.|
|19||Berman P, Ahuja R, Tandon A, Sparks S, Gottret P. Government Health Financing in India: Challenges in achieving ambitious goals. Washington: World Bank, HNP Discussion Paper; 2010.|
|20||Heller P. Who will pay? Washington DC: IMF; 2003.|
|21||McLachlan G, Maynard A, editors. The Public /Private Mix for Health: The relevance and effects of change. London: Nuffield Provincial Hospitals Trust; 1982.|
|22||Ministry of Health and Family Welfare. National Health Accounts India: 2004-05. New Delhi: Ministry of Health and Family Welfare, National Health Accounts Cell, Government of India; 2009:9.|
|23||PWC. Health Care in India. Emerging Market Report. McLean, VA, USA: PriceWaterhouseCoopers; 2007:1.|
|24||Rhodes R. The New Governance: Governing without Government. Polit Stud 1996;44:652-67.|
|25||NAO. The National Programme for IT in the NHS: an update on the delivery of detailed care records systems. Report by the Comptroller and auditor general. London: National Audit Office; 2011.|
|26||De Sola Pool I, Kochen M. Contacts and influence. Soc Networks 1978/79;1:5-51.|