? Walking through these corridors is a humbling experience. To my left is children’s surgery unit at Narayana Hrudayalaya in Bangalore. This is where children from around the world, particularly Pakistan, come and undergo surgeries. I believe this does the largest number of children’s heart surgeries for any hospital in the world. Dr Shetty, what a marvelous thing you have built and it must be a great source of satisfaction.
It is very satisfying to me and my colleagues here.
? Because you have small children here and you have wards full of them.
We get children from 22 countries. And most have complex heart problems. Good thing is something can be done.
? And I presume something can be done to make it affordable for them.
If a solution is not affordable, it is no solution. There is no point in talking about the developments in healthcare if people can’t afford it. So the whole context of our activity is affordable heart surgery to the common man. And with that idea, we have developed all our services.
? And Indians can build skill because from whatever I understand, you made it possible for so many people by building skill. Tell me how do you do it?
The healthcare business, unlike other business, is very much linked with the number of procedures. First of all, as you do more operations, your results get better. A hospital doing 450-500 heart operations in a month has much better results than hospitals doing may be 50 operations in a month. And as you do more operations, your cost of procurement goes down. Today, 40 per cent of the materials we use for the heart operations are disposables and drugs. These are made by multinational companies and as you buy more they will give you better pricing.
? Tell me Dr Shetty, when we talk about skill, I think in India the big problem is also an artificial scarcity. Of hospitals, of doctors, of beds, of specialists, of operation theatres, which is completely undeserved. This is a bit like in the old days, when there was artificial scarcity of scooters, gas connections or telephone connections. You took 20 years to get a Bajaj scooter. Today six salesmen will get you one, and may be a gift also with that.
See the problem of healthcare professionals is that we don’t permit adequate number of positions to train heart specialists. Like this country requires at least 200 cardiologist training positions a year. And the country at the moment has only 80 training positions. The US has 800 training positions. So unless we have more training positions, we won’t be able to train.
? This country requires a lot more doctors.
We get 18, 000 doctors every year. We need more than one lakh doctors every year.
? And we can produce them?
Easily.
? So it is artificial undersupply.
You talk to the highest authorities in healthcare. If you ask them how many doctors are working in the country presently, believe me, nobody knows how many doctors are working. So we need a very different view of creating the adequate number of training positions and maintain the quality of doctors coming out. Unless we address these two issues, putting money in healthcare will not work.
? So we need more than one lakh doctors per year. Or so to say, India can absorb one lakh doctors per year. And we only produce 18, 000. So what we need to do is to scale up our medical infrastructure five times.
Exactly. So it is also disproportionate. South India has a large number of hospitals. So youngsters from north-eastern hill states come to Bangalore, Madras. They become doctors. But when they become doctors down south, they won’t go back to their hometown. They are so used to Bangalore, Madras or Hyderabad. So if you want uniform distribution of healthcare, you have to create hospitals, nursing education institutions in all those north-eastern states.
? Once you easily supply like that, your answer to reservations problem is there.
Easily. Once you have surplus, it is solved. I will give you a small example. Once Karnataka had a shortage of nurses. Four years ago, the government of Karnataka gave permission for 500 nursing schools in one year. In the process, capitation fee for nursing entrances disappeared. The school fee for nursing education has come down. So everyone can afford it. Bad nursing schools are closed. Good nursing schools are doing very well.
? And Karnataka must be supplying nurses to all over India.
This is what is happening. Earlier it was Kerala, now it is gradually Karnataka.
? It that what needs to be done with medical education as well?
You have to. You have no choice. See, if you go to rural India, a majority of the 18, 000 doctors who come out, they all go to major cities and live there. You go to rural India there are no MBBS doctors. So either you produce more MBBS doctors or create alternative specialists and look after rural India.
? What happens if you take this up with policymakers of India, MPs, politicians? Do they understand?
See, everyone seems to be under pressure, primarily because doctors’ lobby is also very powerful. If you tell them that you allow alternative medicine specialists to work in the villages, then there will be some resistance. But things are changing. Now they are understanding.
? Just increasing the number of seats at medical colleges, more medical colleges, will supply more doctors.
This is the only choice with the current problem of reservations.
? Young doctors sitting on streets and starving.
You talk to any of the doctors who are starving. Ask them if they are against a Dalit young man becoming a doctor. They will say no. All they are saying is “give us an opportunity. We are not against others getting a seat”.
? Don’t take my seat?
Yes, create more seats. Give me an opportunity.
? See now, this a very interesting debate, because one argument is that merit gets diluted if you move more seats to reserved categories. Counter argument is that if you are saying increase seats, doesn’t that dilute merit?
See, you can have 1, 000 more seats, maintaining very good quality, because today, you have to realise that there are hundreds of overseas universities of repute who are waiting to enter India, who are willing to offer fantastic education and at a price that Indians can afford. They are willing to give any amount of sponsorship. There are many options. Unless you give them an opportunity to create and you only maintain the quality, you don’t control the number. Things will change. In UK, when FRCS exams take place, 5, 000 to 7, 000 young people take exams. Those who are good will pass, those who are not good, will not.
? There is no limitation of the number of seats. A 6, 000, by Indian standards, would be fighting for a 100 seats. Because one lakh appear for 2, 000 seats in IITs. It’s so brutal. And I always wonder what’s the difference between the top 2, 000 who get in and the 5, 000 who don’t.
In fact, the competition for medical seats is lot more than IITs.
? And you think that’s unfair?
Very unfair. See, we have to give the opportunity. It is up to him whether he will be successful or not. Don’t prevent them from entering. This will lead to frustration. And frustration leads to agitation.
? Is it that what medical students should be demanding instead of no reservations?
Those boys do not know what they want. Unfortunately, if somebody says “we will create alternative seats for you, leave these people alone, ” they all will be willing.
? So if you go to the government to talk on their behalf, what will you tell the government?
I will tell them to just increase the number of seats. You give any number of seats from the government sector to the reserved category, but for other category, if they want to enter into a professional college, create seats, either in private or government.
? It will cost no money to the government?
It doesn’t cost. Education is something which is technically free.
? I think medical education will pay for itself.
Easily.
? You have done this in your colleges.
For all our training programmes, the fee structure is very small which anybody can afford. And a good number of then get sponsorship from institutions, because they are working in our organisation.
? So I believe we are entering your children’s ward now.
Yes.
? Tell me how does the economics of this treatment work because this must be very expensive.
See, the interesting thing is again the economy of scale. Not that all the children suffer from complex problems. Straight-forward children stay for 2-3 days and they leave. Complex ones stay here for 2-3 months. Our adult programme, which is very active, by-pass grafting, that is the one which pays for the operations on the children.
? So what have you done to bring down that cost?
Regular charges for heart operation on a child is Rs 1, 10, 000. But very few of them can afford that money. Today, they come up with Rs 10, 000 to 20, 000 and rest of the money we organise through our charitable wings.
? So you send patients back if they can’t afford it?
No, this is the policy by the management. When the family built it, they were very clear that children belong to the society. If they come to us without money, we cannot turn them away. So we cannot refuse any child from any part of the world.
? Going back to what we were talking about just now. It also surprises people like me who are outside this system, that health system can be such a huge generator of jobs, besides improving the quality of life of our people. And yet such undersupply is incomprehensible.
See, nursing is the only profession in the world where a girl from a low socio-economic strata at the age of 24, can earn Rs 1.5 lakh a month.
? That much?
Yes. We have over a few hundred of our nurses, who are trained here and work in US, Europe and Middle-East, earning that kind of money. Now if you create few thousand good quality nursing schools with accreditation from US and Europe, they will be the people who will transform the economy of the country.
? So they will become like the new H1B visa holder.
Much more than that. Because people in IITs come from middle and upper middle class, whereas these nurses come from lower socio strata.
? And similarly for doctors as well. Because you were telling me the other day that healthcare sector is one of the great employment generators around the world.
See, I gave you the example that in healthcare industry, NHS of UK is the third largest employer in the world. Just looking after 45 million people, they hire the third largest workforce. It is third after the Chinese Army, the Indian Railways. That is the beauty. You invest in healthcare, not only we become a healthy nation, but also a wealthy nation.
? Tell me how will you do it. Tell me about some of the things you are doing, your innovative insurance plans. You are doing a big one in Amethi now.
See, the greatest strength of India are the people. So any programme you want to launch, it should generate revenue from millions of people, a tiny amount of money. We run this insurance called Yashashwani, This is its fourth year. We cover healthcare for about 2.4 million people. Each farmer contributes Rs 10 a month. Earlier, it was Rs 5. We tied up with 175 hospitals. They can go there and get any operation done free of cost. They can even have a heart operation done free of cost, just by paying Rs 10 a month.
? Does it work in real life? How many do it in a month?
In the last three years, over 60, 000 farmers had various types of operations.
? So tell me briefly how does Yashashwani work?
The economics behind Yashashwani is that if you give health insurance for 100 people, less than 1 per cent will require operation. So essentially, 99 people pay for one man’s operation. And because of the size, you have a very low pre-negotiated price with all these hospitals. With over 2.5 million farmers contributing Rs 10 a month, we have Rs 2.5 crore a month. That money gets distributed to 175 hospitals offering surgical treatment.
? How many do you do in a month?
Roughly, a few thousand undergo operation in a month. In the last three years, over 60, 000 people have undergone various operations. Over 2, 000 people have undergone heart operation.
? And now we are in the telemedicine services centre. This is your effort to answer the problem of undersupply. Taking hi-tech medicine to larger populations, where you can’t locate hospitals or doctors.
Exactly. See, the beauty of telemedicine is that when you hear somebody is unwell, 99 per cent of the people who are unwell do not require an operation. Only one per cent of the unwell population requires operation. So if I don’t need to operate on the patient, I don’t need to touch the patient. Then I don’t need to be there, because history can be taken on good quality video-conferencing.
? So how does it work?
The simple thing is it’s a joint venture of ours with Indian Space Research Organisation (ISRO). India is one of the five countries of the world that has the capability to put a satellite in the space. So ISRO gives us the satellite connection for free of cost. For example, here is a child from Kolkata. So the child sits with his parents and a doctor. The doctor gives me the history and I talk to him. And if the child had an angiogram or an X-Ray, it can be transmitted. Then I talk to the family and give them advice. Most of the time, it’s a medical treatment which can be given to them. If they require an operation, they are operated in Kolkata, or they can come here. This is the way it works.
? How many patients are you able to reach out to?
In the last four to four-and-a-half years, we have treated about 20, 000 heart patients. Now we are extending to kidney patients and urology patients.
? There are many other diseases, like metabolic disorders, where doctor basically has to look at the reports.
Exactly. Say a diabetic patient in Africa. You don’t need a diabetologist in Africa. One sitting on this chair here can treat him. So ultimately telemedicine is going to transform the way healthcare is delivered in our lifetime.
? That’s remarkable now. Before we conclude, let me make two requests. One is, give me a message in two sentences for the students who are agitating. And in two sentences, give me a message for the government on how to convert this crisis into an opportunity.
My advice to the students is they should ask the government for an opportunity to become specialists and superspecialists by creating additional seats. And my advice to the government is they should create additional seats by opening the education sector for Indian entrepreneurs and overseas universities. So there is no shortage of teachers and infrastructure.
? And when you say additional seats, you don’t mean 30 per cent more, you mean 500 per cent more.
1, 000 per cent more. You should create surplus of opportunity. So those who want to get into medicine or any other area, they have an opportunity. If they are not good in the field, don’t give them a degree. But don’t prevent them from entering.