Musings about India’s healthcare system after a trip home

And everything the U.S. can learn (or avoid)

I consider myself Indian American but my first home was actually in India. I was born there and we moved to the U.S. when I was a small child. India has remained important to me and I travel back as often as I can. While in India over Christmas, I made it a point to spend time deepening my understanding of the local healthcare system. India is a huge country with a very different economic outlook, but there’s still a lot to learn. I believe one of the ways that the U.S. can improve is to really look at what other countries are doing and integrate their best practices. 

I’m lucky enough to have a cousin - Aheesh Krishna - who’s a physician based in Karnataka, a state in the southwestern region of India. He started out his career in more of a medical research role before realizing he wanted to interface with patients. He studied in Russia at the Smolensk State Medical University before completing a year of practice in India. At that point, he was able to obtain his license. 

The Indian system is complicated but here’s my best explanation of it: It has a public health care system managed by the government with primary health centers and community health centers. These centers provide basic medical services, as well as maternal and child health plus preventative care. There are also District Hospitals that offer more specialized services. 

There’s also a private health care sector, which is rapidly growing. It includes hospitals, clinics and nursing homes. People who can afford it prefer this option given the shorter wait times and more advanced medical technologies on offer.

It’s worth noting that the wealth disparities in India are massive. The top 10 percent of the Indian population holds 77 percent of the total national wealth, compared to 67 percent in the US. On top of that, 16.4 percent of Indians live below the globally defined poverty line, compared to 0.25 percent of Americans. Given all this, my cousin told me, you can imagine dynamics where private care centers can provide world-class care for hefty prices, and unfortunately, numerous associated corruption schemes. 

The concept of health insurance has also gained popularity in India. Many individuals and families opt for health insurance policies to cover medical expenses. Both public and private insurance providers offer various health insurance plans.

As an Indian American, I personally have complex feelings about the healthcare system in India versus the U.S. On the one hand, I see how income disparities massively impact the type of health care you would receive. But on the other hand, I’ve had some personal experiences in India that have been extremely positive. When we were there last summer, my daughter (she was 2-years-old at the time) started making a scary weird wheezing sound. A fever followed. A quick test showed us it was Covid. We were able to take her to a pediatrician right away who saw her within the hour, he also diagnosed her with Croup and prescribed a number of medications. This was summer 2022 when I was yet to see a medication prescription for Covid in the US. She seemed enormously better in just 24 hours, and I was grateful for the doctor’s fast action and decisiveness. 

Here’s the best parts of my interview with my cousin. I edited it somewhat for brevity:

1. AV: What’s unique about the health care system in India? 

AK: “Well health insurance covers traditional medicine but it also recognizes other kinds of medicine like holistic medicine, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH). Many people in India also seek alternative and traditional healthcare approaches. There’s also government initiatives, such as the National Health Mission (NHM) and Ayushman Bharat. Ayushman Bharat aims to provide financial protection and improve healthcare access for vulnerable populations through health insurance.”

2) AV: Can you generally get most medications without a prescription? How does pharmacy work?

AK: “Technically you cannot get most medications without a prescription, and in fact the pharmaceutical sector in India is regulated by the Central Drugs Standard Control Organization, all pharmacists are required to have valid licenses, and prescription drugs in theory are only available through regulated retail or hospital pharmacies with a valid prescription from a licensed medical practitioner. But the reality is that the pharmacy system in India faces challenges such as counterfeit drugs, inadequate regulatory enforcement, black market sales, and the need for increased awareness about the proper use of medications.

With the sheer population of India you also have an unimaginable supply challenge, with there only being one doctor for every 1600 to 2000 people. This relates to pharma in that pharmacists themselves play a crucial role in patient education, dispensing medications, and ensuring that customers understand the proper use of prescribed drugs. And in many rural areas, the pharmacist might function as a doctor. The challenge here is that they are not a physician but acting as one, which often results in over or misguided prescribing in some of the regions with this dynamic.”

3) AV: What is the biggest pro about the healthcare system in India you wish other countries would replicate? And the biggest con?

AK: “As I mentioned above, because of the population, the existing healthcare practitioners have to think and act fast. This results in a decisive, fast system that many other countries seem to lack. Patients can get seen the same day, and doctors see 100 or more patients a day. While a doctor in the U.S. might walk through a number of possibilities and leave a lot of interpretation in the patient’s hand, an Indian doctor would give a diagnosis expediently, and give it in a definitive way. While there is good and bad to this, it seems like American patients can’t see their primary care physician for weeks and turn to the internet for fast answers. The Indian doctor will see you right away and probably give you a better prognosis than the internet. 

The biggest con is related to the pro, fast diagnosis may mean that certain nuances slip through the cracks, and when patients have bad experiences they lose trust in the system and lean on tradition, culture, and often, religion to save them.”

4) AV: What do you think is the biggest health care crisis in India that we're not talking about enough?

AK: “While India faces numerous healthcare challenges (like Vector borne diseases, TB, Non-communicable diseases, maternal and child health, mental health), <2% of the GDP is being utilized for health care. I’d also say the rising acceptance of holistic medicine without rigorous scientific validation poses a unique and potentially far-reaching threat. This surge, fueled by cultural and religious influences, can disproportionately impact marginalized communities who may lack access to evidence-based medical care.”

5) AV: Are you seeing a lot more cardiovascular disease than ever before? I've been reading a lot about the influence of Western dietsL:

AK: “While there's evidence of an increase in cardiovascular disease (CVD) in India, attributing it solely to Western culture or specific food choices can be an oversimplification. Several factors likely contribute to this trend, which include shifting demographics. With increasing urbanization and changing lifestyles, more people are leading sedentary lives and facing dietary changes compared to traditional rural patterns. There’s also the dietary changes: While Western fast-food options may play a role, it's crucial to acknowledge the broader trend of increased fat and sugar consumption across food categories, including traditional celebratory dishes like in weddings and so on. There’s also environmental factors, including rising pollution levels, particularly in urban areas. And of course, the lack of physical activity. Busy work schedules and reliance on technology reduce opportunities for regular exercise, contributing to risks. Therefore, understanding trends in India requires a holistic approach considering various interacting factors rather than solely focusing on specific cultural influences or food choices. This understanding can then guide effective public health interventions and preventive measures.”

6) AV: What's your view of the "wellness" market in India? Do people want to participate in the wellness economy like they do in the United States?

AK: “The Indian wellness market is experiencing rapid growth, driven by a rising interest in healthy lifestyles and diverse traditional practices. Social media plays a significant role in promoting new trends, with people embracing them for both personal health and environmental benefits. However, this enthusiasm can sometimes lead to uncritical acceptance of trends, particularly those with nationalistic or ancestral appeal. Examples include the Satvik movement (two 20-somethings who started it, 1.5 million followers online), which despite its positive aspects, may also include harmful long-term ideologies.

The government's emphasis on Ayurveda has also fostered the growth of unqualified practitioners and influencers, potentially misleading people away from evidence-based medicine. This trend is not limited to India, as evidenced by the blind adoption of supplements like Ashwagandha in the West.”

7) AV: How did you view the success or failures associated with the Covid response?

AK: “While I wasn't directly involved in the frontline response, I believe the Indian government's pandemic response had both successes and areas for improvement. 

Some critical areas that could have been better managed include: 

• Healthcare personnel shortages: The immense workload on doctors and nurses without adequate support was a significant strain. 

• Cremation management: Proper systems for dignified and safe handling of deceased individuals were needed. 

• Preparedness for future waves: Investing in infrastructure like oxygen production capacity in major cities could have mitigated critical shortages during subsequent waves. 

• Medication management: Ensuring appropriate prescription and usage of drugs would have benefited patient outcomes. 

• Grassroots coordination: Stronger communication and collaboration with frontline workers would have optimized resource allocation and response effectiveness.”

8) AV: What do you wish people in the United States knew about the health care system in India?

AK: “While vast differences exist between the Indian and US healthcare systems due to demographics, traditions, and development levels, I believe certain aspects deserve recognition in the West. Like our emphasis on the holistic approach to health; our rigorous medical training that teaches us resourcefulness; the fixation on the doctor-patient relationship; and the access to primary care. 

I hope you enjoyed the interview! I learned a ton talking to my cousin and it truly made me think differently. Where I’m keen to learn more in my next trip to India is really about the social media environment and the impact on mental health, particularly given rising smartphone penetration. I saw a LOT of iPhones, more than I’ve seen previously. It’s also a very young population with Gen Z really defining cultural trends - and I’m fascinated to see how that changes the healthcare system. 

As always, I’m eager to hear from you! Have you interacted with the health system in India? What were your experiences? And more generally, what other countries should the U.S. be learning from? Drop me a line!