Scraping the Bottom of the Pyramid in Indian Healthcare

At least 300 million people in India live below poverty line. And that line is drawn somewhere around an income of ₹1000-1500 per month. If we draw the line double that, the number of poor also doubles.

That's the bottom of the bottomless pyramid.

Half a billion people who earn less than ₹3000 a month.

If you earned that much, what would your priorities be? Food? Shelter? Financial security? Education for a child?

What about your own health? 

Imagine you have diabetes too. The cheapest food you have all around you is rice or wheat based. If you want to decrease carbohydrates and not go hungry, how much can you spend on food? And if your sugars are not under control, would you spend more on a combination of multiple oral hypoglycemic agents that might cost about ₹500 per month?

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Scraping the bottom of the pyramid works beautifully in consumer goods. You build something dirt cheap for the poor. Take a ₹2 shampoo sachet. You can cut down the size of the sachet to make it even cheaper.

You can't sell half a metformin tablet to a poor diabetic.

You can't prescribe a 1 day course of antibiotic.

You can't cure pain with an injection.

But you can. Indeed that's the kind of healthcare that those at the bottom of the pyramid currently receive. Sub-standard, inappropriate, and incomplete.

Because healthcare, unlike consumer goods, doesn't become cheaper at the bottom of the pyramid. It actually becomes more expensive due to the intersection of vulnerabilities.

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There is simply nothing to scrape at the bottom of the pyramid for healthcare.

Someone else has to pay.

A third party.

Could be the government. Could be charity. Could be grants.

But hey! If someone is paying, does it matter whether it is the beneficiary or a third party? 

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That's the logic with which most NGOs in health and government facilities work.

Say you're a doctor in a PHC. The government pays you. You deliver healthcare to the poor. Simple economics.

Where does the government get money? It raises money through taxes, etc.

What if you're a non-governmental organization? You get donations/grants in what is called "fund-raising".

(There's of course a cross-subsidization model which may look different superficially, but isn't very different in the larger scheme of things)

Is this any different from first party payment?

Very different!

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The first issue is that of accountability. Accountability lies where money flows from. If my healthcare is paid for by someone else, my healthcare provider isn't accountable to me.

Public health facilities are not accountable to the poor that it serves healthcare to. They are only accountable to the hierarchy above them.

NGOs are not accountable to the poor that they serve healthcare to either. They are only accountable to funders. (Typically NGOs which are able to diversify their funding source is able to decrease the power that funders have to some extent by dividing the funders into many).

Why, though? Because accountability without control doesn't work.

If you want to hold someone accountable, you have to be able to control them in some way.

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When there is no accountability, the next issue is that of quality.

In first party payment, quality assessment is decentralized. Every individual makes their own assessment about the quality of care they receive. And this instantly translates to payment, recurring visits, etc.

In third party payment, quality assessment is different. It uses "metrics". And metrics are difficult. Funders typically look at fancy metrics like "decrease in maternal mortality rate". The problem with such "key" metrics are that they capture very little nuance and sometimes no meaning.

To government, for example, where the whole hierarchy is just supplying metrics to someone else, it becomes a complete number game. (Recommended reading: Chasing Numbers, Betraying People)

To NGO funders who have a bit more involved staffing structure it goes beyond numbers to also include "reports" filled with presentation-worthy photographs.

It no longer matters whether the individual receives quality healthcare as long as the metrics and reports are looking good.

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Now let us look at something totally different. The CSR sector spent about 2600 crore rupees in health in 2020-21 FY. That's about 1% of India's national health budget. As per national health accounts 2017-18, the combined contribution of NGOs, corporates, foreign aid, etc to India's health expenditures is less than 10%. 

By all means, the government is the single largest provider and payer of healthcare for the bottom half of India's pyramid.

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If you read all of this together, there are certain insights to be gained about why certain things are the way they are.

Why do NGOs build/research "models"? Because the kind of money it takes to deliver care to a population larger than what "model"s serve is hard for NGOs to come by.

Why does everyone want to build software? Because software can (theoretically) "scale" to large populations without a lot of money.

Why do NGOs focus on showcasing "reach"? Because numbers mean impact for funders. And creating the impression of quality is more important than quality.

Why does public health system get away with delivering poor quality healthcare? Because there's no real way citizens can hold health system accountable. The constitutionally mandated way they can do so has been hijacked by issues like religion, party, and war.

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What to do about all this?

1. Look deeper than numbers - everywhere. In fact, don't look at numbers, at all. Numbers are meant to hide and deceive.
2. Think critically. Especially on stories around impact. Reach isn't impact. Touch-points aren't healthcare. Technology can't solve problems that technology can't solve. Innovation is a buzzword unless and until innovation leads to inclusion.
3. Be political. In thoughts, actions, and choices.
4. Be aware, call out, and discuss things like above with raw honesty. Reality is shaped by what we accept silently.