Invest in health care, not just in AIIMS clones

The All India Institute of Medical Sciences (AIIMS, Delhi) was established to be a national institute of excellence, in medical research and for training doctors. A secondary expectation was that AIIMS-trained doctors would create new centres of excellence. AIIMS has partly achieved the first objective: Its faculty publishes more research papers than their counterparts at peer institutions within India. The second aim was never met since the elitist ideals imbibed by AIIMS-trained doctors meant that they were unlikely to go anywhere else in India except to another elite institution or overseas.

AIIMS’ reputation makes it a magnet for patients from outside Delhi: It sees more than 7,000 patients each day of whom a large chunk comes from Delhi’s neighbouring states. If AIIMS is such a magnet for patients, it makes good sense to set up more AIIMS-like institutions. This is the logic driving the establishment of 25 AIIMS clones. But this may inhibit the progress of primary health care and district hospitals. Which patient would want to be treated at a district hospital when an AIIMS is a bus ride away?

When a foundation for basic public health care does not exist, then constructing a costly super-speciality tertiary health care facility will deal a death blow to any attempt to push the agenda of public health. First, it will soak up resources (capital and personnel), leaving only leftovers for public health. Second, it will accelerate the race among private hospitals to build sophisticated and costly infrastructure to compete with the nearby AIIMS. The private hospitals will then use all means available to fill the capacity, leading to a ballooning of wasteful care and costs. Finally, plonking an AIIMS all across India will act as a strong disincentive for local governments to build primary and secondary care infrastructure. Yet another unintended consequence of establishing these islands of excellence and plenty is that they will concentrate large numbers of patients within their premises, impairing quality of service and increasing problems such as antibiotic resistance and iatrogenic morbidity. It is not that we do not need AIIMS-like institutions. But we may need four to six such institutions. Like AIIMS, Delhi, they must be designed specifically to carry out advanced biomedical research and preferably operate as postgraduate institutions that focus on the introduction of cutting-edge methods in health care. Co-locating them with engineering and science research institutions can have a synergistic effect.

To deliver health care at scale without compromising quality, we need a different kind of hospital. First, we need our hospitals to be embedded in and seamlessly integrated within a network of health care providers from primary to tertiary care. A system of referrals should determine who needs to go to a tertiary care facility for treatment. Plain vanilla multi-speciality hospitals should give way to a mix of focused care facilities (e.g., hospitals that specialise in a single speciality, like cardiac care), emergency care facilities and community hospitals (that can take on the workload of routine procedures). Only such a differentiated and yet fully integrated health care network can provide high quality care close to where the patients live at a cost the national budget can bear.

For a big chunk of our population, quality health care is a luxury. Giving them access to a super-speciality hospital when their basic health needs are not met is like Mary Antoinette asking starving Parisians to eat cake. Instead of asking them to go to a distant AIIMS, the State should discharge its responsibility in providing them seamless end-toend health care that starts close to their home at a primary health centre.