INTRODUCTION

Healthcare has become one of India’s largest sectors, both in terms of revenue and
employment. Healthcare comprises hospitals, medical devices, clinical trials, outsourcing,
telemedicine, medical tourism, health insurance and medical equipment. The Indian healthcare
sector is growing at a brisk pace due to its strengthening coverage, services, and increasing
expenditure by public as well private players.

India’s healthcare delivery system is categorised into two major components - public and
private. The government, i.e. public healthcare system, comprises limited secondary and tertiary
care institutions in key cities and focuses on providing basic healthcare facilities in the form of
primary healthcare centres (PHCs) in rural areas. The private sector provides majority of
secondary, tertiary, and quaternary care institutions with major concentration in metros, tier-I
and tier-II cities.

India's competitive advantage lies in its large pool of well-trained medical professionals. India
is also cost competitive compared to its peers in Asia and western countries. The cost of surgery
in India is about one-tenth of that in the US or Western Europe. The low cost of medical services
has resulted in a rise in the country’s medical tourism, attracting patients from across the world.
Moreover, India has emerged as a hub for R&D activities for international players due to its
relatively low cost of clinical research.

Traditional and Ancient Healthcare

Healthcare eventually started as traditional healthcare where different cultures did a

purposeful study on healthcare. One of the oldest examples comes from Mesopotamia known as
“Treatise of Medical Diagnosis and Prognoses,” where they made tablets based on rational
observations of the body. 19th Century turned out to be a turning point in the healthcare industry.
There were numerous advances in the technological, chemical and biological fields which also
gave the physicians an opportunity to learn more about the diseases and better understanding to
treat ailments

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 Healthcare quality measurement is the accepted criteria for assessing the effectiveness of
health care delivery on a global scale (Kleinman & Dougherty, 2013). This article is Part one of
the history of healthcare quality and will present the first 100 years of development.

The history of healthcare quality prior to 1960 is a fragmented collection of unrelated events
rather than a streamlined organized effort. To appreciate how these events have evolved as the
foundation for healthcare quality improvement, broad categories have been developed to identify
global innovations in Europe, Asia and The United States (U.S.). Much of the history is so
embedded in day-to-day medical-surgical practice and Quality Improvement Activities (QIA’s)
that it is taken for granted. Undoubtedly there will be familiarity with some, but not all of the
events discussed.

Malcolm Gladwell’s theory of Tipping Point (Gladwell, 2000) ideas, behaviors and messages
is utilized to help navigate these events in an orderly fashion and provide structure and
framework to the history of healthcare quality. Tipping Points are the phenomenon that precepts
change before it becomes a norm. Gladwell identifies that Tipping Points depend heavily on
people with a set of rare social gifts. Florence Nightingale was such a person; therefore the
history of healthcare quality begins with her. Table 1 provides a snapshot of these important
events.

Table 1. Chronological summary of key tipping points, individuals by year.

Year(s) Key tipping points Key individuals responsible Country of origin

1854 Quality improvement Nightingale England

documentation

1861 Sanitary commissions Barton USA

1862, 1918 Improvisation & Pasteur, Blue France, USA

innovation

1879 Sterilization Chamberland France

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 Year(s) Key tipping points Key individuals responsible Country of origin

1895,1956, Technology Rontgen, Safar, Laerdal Germany, USA,

1960 France, Norway

1910 Education Flexner USA

1881–1955 Pharmaceuticals Pasteur, von Behring, Kitasato, France, Germany,

Descombey, Salk, Kendrick, Japan, USA,
Eldering, Pittman, Fleming England

1883–1945 Healthcare financing Bismark, Beveridge, Kaiser Germany,

England, USA

1908 The role of industry Ford USA

and mass production

Impacts of various stages in history

I find it very interesting that even colonialism had an impact at the healthcare
industry. Colonialism not only helped in exchange of trade and goods but also the exchange of
diseases. Physicians now had to also worry about the diseases that were coming in because of the
urbanization and increasing population densities. This also gave a rise to development of new
trends in medical systems. And new developments were taking shape – Vaccinations, prevention
and Treatments.

In 20th Century though, the focus from the generalized pathology shifted to specific diseases.
It is also known as the therapeutic revolution also understood as the moment when medicine
began to work. Now practitioners wanted to focus on the effectiveness of the medicines. It all

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began with Pasteur – father of germ theory. There were great advances in relation to diseases
such as leprosy, anthrax, tuberculosis, plague, and malaria. I can’t even imagine what life could
have been without the development of treatments for these diseases.

Eradication campaigns were different campaigns launched by WHO designed to specifically

eradicate diseases causing widespread deaths like smallpox, malaria. While very effective in
industrialized countries, the diseases were still haunting the developing nations. These
campaigns also made people in the healthcare industry aware of how vulnerable they are despite
the modern advances in the technology.

“ Health for all” was a goal setup in 1978’s Alma Ata Declaration/International Conference on
Primary Health Care. Its main agenda was to express the need for urgent action by all
governments, all health and development workers, and the world community to protect and
promote the health of all people.

2. Quality improvement documentation

In 1854, British troops fought in Crimea and the surrounding area to force Russians to leave
the Turkish territories of Moldavia and Wallachia. Cholera and diarrhea were responsible for a
great deal of mortality among the British troops, and the British government sent a group of
nurses to accompany Florence Nightingale to Turkey to help care for the soldiers. Within six
months of the arrival of Florence Nightingale, the mortality rate from disease dropped from
42.7% to 2.2%.

Some of Nightingale’s specific improvements were, the reduction of overcrowding (beds

had to spaced three feet apart), provision of ventilation, the removal of Calvary horses that were
being stabled in the hospital basement, assuring the sewers leading from the hospital were
flushed several times a day and disinfecting the latrines/drains with peat charcoal (Nightingale,
1863).

She documented that if improvements had been implemented prior to admitting soldiers to
the hospital, thousands of needless deaths would have been prevented. Her meticulous records
were a key to present day statistical quality measurement, and she was an innovator in the
collection, tabulation, interpretation, and graphical display of descriptive statistics. She named

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her graphical data display a “Coxcomb” which is known today as a pie-chart (Joint Commission
Resources, 1999).

Florence Nightingale was most likely influenced by evidence linking hand-washing and
cleanliness to disease reduction discovered by Dr. Ignaz Semmelweis in Vienna’s maternity
wards during the 1840s (Joint Commission Resources, 1999).

3. Sanitary commissions

Approximately 7 years later and an ocean away, another pioneer was hard at work ministering
to soldiers in a different war. As the American civil war formally began in 1861, the Sanitary
Commission was founded as a partnership or alliance of relief organizations. It was based on
lessons learned from the Crimean War with the purpose of promoting clean and healthy
conditions in the Union Army camps and hospitals.

Clara Barton was a civilian volunteer who supervised nursing care to soldiers primarily in the
state of Virginia to help meet the goals of the Sanitary Commission. She was assisted by Dr.
Elizabeth Blackwell, who worked with Florence Nightingale in England and was the first female
to graduate from medical school in the U.S. (Oats, 1994).

For every man wounded in battle during the Civil War, two died from dysentery, typhoid and
malaria. Sanitary Commission Agents patrolled Union Army camps inspecting the living
conditions and the hospitals, organized diet kitchens, made bandages, and in Cleveland, Ohio –
conducted door to door “blanket raids” to prevent soldiers from sleeping on the ground at night.
The Sanitation Agents were considered to be critical to the success of the Union Army during the
Civil War (Lewis, 2013).

4. Improvisation and innovation

Historians identify Louis Pasteur as one of the “greatest benefactors to humanity of all time”.
He was a French chemist who discovered that disease was caused by microorganisms or
microbes, which later became known as germ theory (Chamberland, 1904). This evidence led to
the wide-scale adoption of antiseptic practices by physicians and hospitals throughout Europe
and eventually in the U.S.

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 Pasteur’s research also led to the development of “pasteurization,” which utilizes heat to
destroy harmful microbes in perishable food while leaving the food undamaged.

Another innovator was Surgeon General, Dr. Rupert Blue, who had the daunting responsibility
of providing leadership in America during the worst outbreak of disease in U.S. history (The
United States Department of Health and Human Services, 2013a). The Influenza Pandemic of
1918 killed fifty (50) million or 1/5 of the world’s population, representing more people than
died during World War I (The United States Department of Health and Human Services, 2013b).

Dr. Blue’s extensive experience with healthcare improvement included eradicating rats in the
turn-of-the-century San Francisco that were responsible for an outbreak of bubonic plague, and
leading mosquito control during the opening of the Panama Canal (The United States
Department of Health and Human Services, 2013a).

During the Influenza Pandemic, Dr. Blue’s quality tools were, quarantine (including ships
entering the country), mandatory medical exams for all immigrants entering the country,
communication in the form of weekly newsletters that contained information about the latest
outbreaks, and the results of influenza research conducted at the Hygienic Laboratory which
continues to exist today. In addition to the pandemic, Dr. Blue was faced with outbreaks
of polio, smallpox, and typhoid. He knew how disease was spread but science had not advanced
enough to stop it. He also did not have antibiotics at his disposal which would have benefitted
approximately half of the influenza victims that died from secondary bacterial infections
and sepsis (Gernhart, 1999).

In the United States, efforts to contain influenza in 1918 focused the use of quarantine and
masks while in public, similar to the response by countries affected by the outbreak of SARS in
2003 (Center for Disease Control, 2012). The enforcement of Dr. Rupert Blue’s healthcare
quality plan fell to the police departments and public transportation employees.

Dr. Blue is viewed by many historians to represent the kind of visionary quality leader needed
in the event of global disease pandemics of the future. The medical records kept during the 1918
influenza pandemic continue to be some of the most researched archival documents used by
international scientists today. They serve to inform how we should respond to a similar

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widespread outbreak of biological disease, and provide data on the long term effects of the flu on
pregnant woman.

5. Sterilization

An early prototype of the modern-day autoclave was invented in 1879 by Dr. Charles
Chamberland, a French physician and biologist (Chamberland, 1904). His research was
influenced by journal entries from the year 1679 by a British physicist, Dr. Denis Papin who
invented the pressure cooker and research conducted by Louis Pasteur, with whom he frequently
collaborated (Encyclopedia Britannica Science and Technology, 2013).

Chamberland’s doctoral thesis, “Research Concerning the Origin and Development of

Microscopic Organisms” led to the development of the Chamberland Filter, a piece of porous
porcelain that filtered microorganisms from water (Chamberland, 1904). He then designed the
Chamberland Autoclave to heat solutions above their boiling point, effectively destroying
dangerous microorganisms. The first Chamberland Autoclave was manufactured for laboratory
use in Paris, France by Wiesnegg Engineering (Block, 2001).

6. Technology

In 1895 Wilhelm Conrad Rontgen accidently discovered X-rays in Germany by producing a

fast stream of electrons that come to a sudden stop at a metal plate. His discovery revolutionized
the ability to diagnose and musculo-skeletal disorders and injuries (Assmus, 1995). Advances in
radiology primarily in France eventually led to the treatment of cancerous tumors and he won the
Nobel Prize for Physics in 1901 (Nobel Prize Organization, 2013a).

Another three time Nobel Prize nominee was, Dr. Peter Safar, known as the architect of
Intensive Care. Developed an A–B–C technique (which stood for airway/breathing/circulation)
for cardio-pulmonary resuscitation in 1956 at Baltimore City Hospital, noting that the best results
were achieved by tilting the head back and pulling the jaw forward. His research was published
in the Journal of the American Medical Association in 1958 (Srikameswaran, 2003).

The evidence provided by his research helped CPR gain world-wide acceptance. He
approached a Norwegian toymaker; Asmund Laerdal to develop a realistic mannequin for CPR

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training, the resulting prototype became the life-size Resusci-Anne doll. This prototype was the
basis for much of the emergency simulation training that is now a standard part of healthcare
education (Srikameswaran, 2003).

In the late 1950s Dr. Safar revolutionized the quality of pre-hospital care by convincing the
Baltimore City Fire Department to improve the transport of patients to hospitals utilizing fully
equipped ambulances staffed with emergency medical technicians rather than the ordinary
station wagons or hearses that were being used. He is also credited for establishing the first 24-
hour Intensive Care Unit in the United States and is considered a giant in the field of
resuscitation research (Sullivan, 2003).

7. Education

The first medical school in the United States was established in 1765 at the College of
Philadelphia (now known as the University of Pennsylvania). The faculty was trained in Scotland
and England, and it was located a few blocks from Pennsylvania Hospital co-founded by
Benjamin Franklin. After the War of 1812, there was a rapid increase in medical schools across
the country, but the quality was inconsistent (Porter, 2002).

In 1910, Abraham Flexner presented research on the state of medical education in the United
States, which was sponsored by the Carnegie Foundation (Flexner, 2010).

His results revealed that there was often no formal tuition, no prerequisite academic
preparation, and written exams were not mandatory (Beck, 2004). There were too many medical
schools, 155 to be exact and only 16 of those required 2 years of college courses prior to
admission – the remaining 139 may or may not have required a high school diploma (Flexner,
2010).

Flexner proposed a four-year medical school curriculum – two years of basic science
education followed by two years of clinical training. He also proposed the requirements for
admission to include a high school diploma and a minimum of two years of college science. The
report resulted in the closure of many medical schools that were not incorporated within a
university. In 1935 there were only 66 medical schools that survived the reform (Flexner, 2010).

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 These improvements in medical education were followed by standardized testing for medical
school admissions and the Medical College Admission Test (MCAT) was developed in 1928
(McGaghie, 2002). The MCAT was a major step in the beginning of the quality journey for
medicine.

Abraham Flexner continues to be honored today by the Association of American Medical

Colleges, who confers a $10,000.00 award annually upon a physician that recognizes the highest
standards in U.S. medical education (Association of American Medical Colleges, 2010).

8. Pharmaceuticals.

Of all the advances in healthcare quality, few can rival the discovery of vaccines. Some of the
more well-known vaccines discovered between 1881 and 1955 are:

Anthrax – discovered in 1881 by Louis Pasteur who also discovered the Rabies vaccine in 1885.

Diphtheria – discovered by Emil von Behring and Shibasaburo Kitasato in 1891.

Tetanus – discovered in 1924 by Pierre Descombey.

Polio – discovered by Jonas Salk in 1955.

Pertussis – discovered by Pearl Kendrick, Grace Eldering and Margaret Pittman in 1949.

In 1928, the “Wonder Drug” penicillin was discovered by Sir Alexander Fleming in England.

Early in his medical life, Fleming became interested in the natural bacterial action of the blood
and in antiseptics (Nobel Prize Organization, 2013b).

He was known as a “sloppy scientist,” cultures that he worked on were constantly forgotten,
and his lab, was normally in a state of great disorder. After returning from a month long
vacation, He observed that mold had developed accidently on a staphylococcus culture plate and
that the mold had created a bacteria-free circle around itself. His experiments led to the discovery
of penicillin in 1928 (Nobel Prize Organization, 2013b).

Prior to the discovery of penicillin, death could occur with minor injuries, such as scrapes and
from diseases such as strep throat, syphilis and gonorrhea. The mortality rate for soldiers from

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pneumonia was 18% during WWI. Interestingly the death rate today from
penicillin resistant pneumonia is 19.4% (Nobel Prize Organization, 2013b).

Alexander Fleming was elected Fellow of the Royal Society in 1943, Knighted in 1944 and in
1945 won the Nobel Prize for Physiology and Medicine (Nobel Prize Organization, 2013b).

9. Healthcare financing

During the 19th and 20th centuries, payment for healthcare emerged in three different
countries. Each went about this in a different way, produced different results and has different
quality outcomes as a result.

9.1. Germany

Chancellor Otto Von Bismarck who designed a state run medical insurance program in 1883.
The years between 1871 and 1890 are known as The Bismarck Era and Otto is affectionately
known as the father of healthcare in Germany (Sawicki & Bastian, 2008).

Between 1883 and 1889, health insurance in Germany was defined as treatment & sick pay for
up to 13 weeks. The Bismarck vision was a centrally administered and government financed
healthcare system. Germany continues to have a healthcare system grounded in the Bismarck
Era. (European Observatory on Health Care Systems, 2000, Sawicki and Bastian, 2008).

9.2. England

William Beveridge, is responsible for the ‘Beveridge Report’ published in 1942 following after
the end of World War II in the United Kingdom. The report offered options on how the British
healthcare system should be rebuilt. This included the establishment of a National Health
Service in 1948 with free medical treatment for all as priority (British Broadcasting Company
Historic Figures, 2013).

The Beveridge Model of a National Health Service remains in existence today and both the
Beveridge and Bismarck style of Healthcare Systems served as the models for universal
coverage across the rest of Europe.

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9.3. The United States

While German and British healthcare models were flourishing in Europe, healthcare in the U.S.
was a jumble of voluntary, religious and charitable initiatives, such as relief for the elderly or the
poverty stricken. The exception was for those who had money and could pay for medicine and
care. It remained this way until the 20th century.

Henry Kaiser, was an American industrialist who owned steel mills, shipyards and pioneered
construction with heavy equipment. In the 1930s and 40s, he wanted to provide a health plan for
construction workers in his employ and designed a prepaid program. Following the model he
established for his own employees, these pre-paid programs evolved into Kaiser Permanente
which opened to the public in 1945, in Oakland, California. Today it exists as the
largest HMO in the world (Kaiser Permanente History, 2006).

The predominantly employer based health insurance system in the United States developed in a
fragmented, decentralized manner, with private insurers and the government eventually filling
some, but not all of the gaps.

The overall quality of the German system today is currently ranked 25th best in the world by
the World Health Organization, the United Kingdom is ranked 18th and the United States is
ranked 37th (The World Health Organization., 2000).

10. The role of industry and mass production

Deliberate quality improvement efforts were finding a foothold in industries other than health
care between 1860 and 1960.

Henry Ford is credited with saying, “we are charged with discovering the best way of doing
everything”, a motto that could easily apply to healthcare even though it was meant for
automobiles (Zarbo & D’Angelo, 2006).

Based upon our historical research, Florence Nightingale’s three key contributions are (a) the
measurement of quality improvement in all of healthcare, which is the foundation upon which
current international benchmarks for excellence are identified today; (b) the importance of proper

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documentation and presentation of measurement results and (c) the value of generating buy-in
from others to support healthcare quality intervention.

It is the legacy of Florence Nightingale that stirs the sense of quality assessment in what we
have come to know as modern nursing.

Development movement coincided with the post-World War II era and was based on the belief
that increasing economic development would benefit the entire world, despite inequalities that
might result. The development ideology held both the implicit and explicit goal of a globalized,
modern world that left behind ancient philosophies in pursuit of economic progress

Even though now Healthcare is a global industry but because the healthcare has always
traditionally been considered a local industry, specific to regions and countries the practices and
development of healthcare across countries vary. When some of the countries have been
successful in establishing a robust healthcare system, some countries still lag behind by lot of
factors. 

Market size

The Indian healthcare sector is expected to record a three-fold rise, growing at a CAGR of 22%
between 2016–22 to reach US$ 372 billion in 2022 from US$ 110 billion in 2016. By FY22,
Indian healthcare infrastructure is expected to reach US$ 349.1 billion.

In the Economic Survey of 2022, India’s public expenditure on healthcare stood at 2.1% of
GDP in 2021-22 against 1.8% in 2020-21 and 1.3% in 2019-20.

In FY22, premiums underwritten by health insurance companies grew to Rs. 73,582.13 crore
(US$ 9.21 billion). The health segment has a 33.33% share in the total gross written premiums
earned in the country.

The Indian medical tourism market was valued at US$ 2.89 billion in 2020 and is expected to
reach US$ 13.42 billion by 2026. According to India Tourism Statistics at a Glance 2020 report,
close to 697,300 foreign tourists came for medical treatment in India in FY19. India has been
ranked 10th in the Medical Tourism Index (MTI) for 2020-21 out of 46 destinations by the
Medical Tourism Association.

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The e-health market size is estimated to reach US$ 10.6 billion by 2025.

As per information provided to the Lok Sabha by the Minister of Health & Family Welfare,
Dr. Bharati Pravin Pawar, the doctor population ratio in the country is 1:854, assuming 80%
availability of 12.68 lakh registered allopathic doctors and 5.65 lakh AYUSH doctors.
Medicine, dentistry, pharmacy, midwifery, nursing, optometry, audiology, psychology, occupatio
nal therapy, physical therapy, athletic training, and other health professions all constitute health
care. It includes work done in providing primary care, secondary care, and tertiary care, as well
as in public health.

Access to health care may vary across countries, communities, and individuals, influenced
by social and economic conditions as well as health policies. Providing health care services
means "the timely use of personal health services to achieve the best possible health
outcomes".Factors to consider in terms of health care access include financial limitations (such
as insurance coverage), geographical and logistical barriers (such as additional transportation
costs and the possibility to take paid time off work to use such
services), sociocultural expectations, and personal limitations (lack of ability to communicate
with health care providers, poor health literacy, low income). Limitations to health care services
affects negatively the use of medical services, the efficacy of treatments, and overall outcome
(well-being, mortality rates).

Health systems are organizations established to meet the health needs of targeted populations.
According to the World Health Organization (WHO), a well-functioning health care system
requires a financing mechanism, a well-trained and adequately paid workforce, reliable
information on which to base decisions and policies, and well-maintained health facilities to
deliver quality medicines and technologies.

An efficient health care system can contribute to a significant part of a country's economy,

development, and industrialization. Health care is conventionally regarded as an important
determinant in promoting the general physical and mental health and well-being of people
around the world. An example of this was the worldwide eradication of smallpox in 1980,
declared by the WHO as the first disease in human history to be eliminated by deliberate health
care interventions.

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 The delivery of modern health care depends on groups of
trained professionals and paraprofessionals coming together as interdisciplinary teams.This
includes

In medicine, psychology, physiotherapy, nursing, dentistry, midwifery and allied health,
along with many others such as public health practitioners, community health
workers and assistive personnel, who systematically provide personal and population-based
preventive, curative and rehabilitative care services.

While the definitions of the various types of health care vary depending on the different
cultural, political, organizational, and disciplinary perspectives, there appears to be some
consensus that primary care constitutes the first element of a continuing health care process and
may also include the provision of secondary and tertiary levels of care. Health care can be
defined as either public or private.[citation needed]

The emergency room is often a frontline venue for the delivery of primary medical care.

Primary care

Hospital train "Therapist Matvei Mudrov" in Khabarovsk, Russia-

Primary care refers to the work of health professionals who act as a first point of consultation
for all patients within the health care system. Such a professional would usually be a primary
care physician, such as a general practitioner or family physician. Another professional would be
a licensed independent practitioner such as a physiotherapist, or a non-physician primary care
provider such as a physician assistant or nurse practitioner. Depending on the locality, health
system organization the patient may see another health care professional first, such as
a pharmacist or nurse. Depending on the nature of the health condition, patients may
be referred for secondary or tertiary care.

Primary care is often used as the term for the health care services that play a role in the local
community. It can be provided in different settings, such as Urgent care centers that provide
same-day appointments or services on a walk-in basis.

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 Primary care involves the widest scope of health care, including all ages of patients, patients
of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and
patients with all types of acute and chronic physical, mental and social health issues,
including multiple chronic diseases. Consequently, a primary care practitioner must possess a
wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as
patients usually prefer to consult the same practitioner for routine check-ups and preventive
care, health education, and every time they require an initial consultation about a new health
problem. The International Classification of Primary Care (ICPC) is a standardized tool for
understanding and analyzing information on interventions in primary care based on the reason
for the patient's visit.

Common chronic illnesses usually treated in primary care may include, for
example, hypertension, diabetes, asthma, COPD, depression and anxiety, back
pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child
health care services, such as family planning services and vaccinations. In the United States, the
2013 National Health Interview Survey found that skin disorders (42.7%), osteoarthritis and joint
disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper
respiratory tract disease (22.1%, excluding asthma) were the most common reasons for accessing
a physician.

In the United States, primary care physicians have begun to deliver primary care outside of
the managed care (insurance-billing) system through direct primary care which is a subset of the
more familiar concierge medicine. Physicians in this model bill patients directly for services,
either on a pre-paid monthly, quarterly, or annual basis, or bill for each service in the office.
Examples of direct primary care practices include Foundation Health in Colorado and Qliance in
Washington.

In the context of global population aging, with increasing numbers of older adults at greater
risk of chronic non-communicable diseases, rapidly increasing demand for primary care services
is expected in both developed and developing countries. The World Health
Organization attributes the provision of essential primary care as an integral component of an
inclusive primary health care strategy

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Secondary care

Jackson Memorial Hospital in Miami, the primary teaching hospital of the University of

Miami's Leonard M. Miller School of Medicine and the largest hospital in the United States with
1,547 beds.

Secondary care includes acute care: necessary treatment for a short period of time for a brief
but serious illness, injury, or other health condition. This care is often found in
a hospital emergency department. Secondary care also includes skilled attendance
during childbirth, intensive care, and medical imaging services.

The term "secondary care" is sometimes used synonymously with "hospital care". However,
many secondary care providers, such as psychiatrists, clinical psychologists, occupational
therapists, most dental specialties or physiotherapists, do not necessarily work in hospitals. Some
primary care services are delivered within hospitals. Depending on the organization and policies
of the national health system, patients may be required to see a primary care provider for
a referral before they can access secondary care.

In countries that operate under a mixed market health care system, some physicians limit their
practice to secondary care by requiring patients to see a primary care provider first. This
restriction may be imposed under the terms of the payment agreements in private or group health
insurance plans. In other cases, medical specialists may see patients without a referral, and
patients may decide whether self-referral is preferred.

In other countries patient self-referral to a medical specialist for secondary care is rare as prior
referral from another physician (either a primary care physician or another specialist) is
considered necessary, regardless of whether the funding is from private insurance
schemes or national health insurance.

Allied health professionals, such as physical therapists, respiratory therapists, occupational

therapists, speech therapists, and dietitians, also generally work in secondary care, accessed
through either patient self-referral or through physician referral.

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Tertiary care

National Hospital for Neurology and Neurosurgery in London, United Kingdom is a specialist

neurological hospital.

Tertiary care is specialized consultative health care, usually for inpatients and on referral from
a primary or secondary health professional, in a facility that has personnel and facilities for
advanced medical investigation and treatment, such as a tertiary referral hospital.

Examples of tertiary care services are cancer management, neurosurgery, cardiac

surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative,
and other complex medical and surgical interventions.

Quaternary care

The term quaternary care is sometimes used as an extension of tertiary care in reference to

advanced levels of medicine which are highly specialized and not widely accessed. Experimental
medicine and some types of uncommon diagnostic or surgical procedures are considered
quaternary care. These services are usually only offered in a limited number of regional or
national health care centers.

Home and community care

Many types of health care interventions are delivered outside of health facilities. They include
many interventions of public health interest, such as food safety surveillance, distribution
of condoms and needle-exchange programs for the prevention of transmissible diseases.

They also include the services of professionals in residential and community settings in
support of self-care, home care, long-term care, assisted living, treatment for substance use
disorders among other types of health and social care services.

Community rehabilitation services can assist with mobility and independence after the loss of
limbs or loss of function. This can include prostheses, orthotics, or wheelchairs.

Many countries, especially in the west, are dealing with aging populations, so one of the
priorities of the health care system is to help seniors live full, independent lives in the comfort of

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their own homes. There is an entire section of health care geared to providing seniors with help
in day-to-day activities at home such as transportation to and from doctor's appointments along
with many other activities that are essential for their health and well-being. Although they
provide home care for older adults in cooperation, family members and care workers may harbor
diverging attitudes and values towards their joint efforts. This state of affairs presents a challenge
for the design of ICT (information and communication technology) for home care.

Because statistics show that over 80 million Americans have taken time off of their primary
employment to care for a loved one,many countries have begun offering programs such as the
Consumer Directed Personal Assistant Program to allow family members to take care of their
loved ones without giving up their entire income.

With obesity in children rapidly becoming a major concern, health services often set up
programs in schools aimed at educating children about nutritional eating habits, making physical
education a requirement and teaching young adolescents to have a positive self-image.

Ratings

Health care ratings are ratings or evaluations of health care used to evaluate the process of
care and health care structures and/or outcomes of health care services. This information is
translated into report cards that are generated by quality organizations, nonprofit, consumer
groups and media. This evaluation of quality is based on measures of:

 hospital quality

 health plan quality

 physician quality

 quality for other health professionals

 of patient experience

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Related sectors

Health care extends beyond the delivery of services to patients, encompassing many related
sectors, and is set within a bigger picture of financing and governance structures.

Health system

A health system, also sometimes referred to as health care system or healthcare system, is the
organization of people, institutions, and resources that deliver health care services to populations
in need.

Healthcare industry

The healthcare industry incorporates several sectors that are dedicated to providing health

care services and products. As a basic framework for defining the sector, the United
Nations' International Standard Industrial Classification categorizes health care as generally
consisting of hospital activities, medical and dental practice activities, and "other human health
activities." The last class involves activities of, or under the supervision of, nurses, midwives,
physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health
facilities, patient advocate  or other allied health professions.

In addition, according to industry and market classifications, such as the Global Industry

Classification Standard and the Industry Classification Benchmark, health care includes many
categories of medical equipment, instruments and services including biotechnology, diagnostic
laboratories and substances, drug manufacturing and delivery.

Health care research

The quantity and quality of many health care interventions are improved through the results
of science, such as advanced through the medical model of health which focuses on the
eradication of illness through diagnosis and effective treatment. Many important advances have
been made through health research, biomedical research and pharmaceutical research, which
form the basis for evidence-based medicine and evidence-based practice in health care delivery.
Health care research frequently engages directly with patients, and as such issues for whom to
engage and how to engage with them become important to consider when seeking to actively

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include them in studies. While single best practice does not exist, the results of a systematic
review on patient engagement suggest that research methods for patient selection need to account
for both patient availability and willingness to engage.

Health services research can lead to greater efficiency and equitable delivery of health care
interventions, as advanced through the social model of health and disability, which emphasizes
the societal changes that can be made to make populations healthier. Results from health services
research often form the basis of evidence-based policy in health care systems. Health services
research is also aided by initiatives in the field of artificial intelligence for the development of
systems of health assessment that are clinically useful, timely, sensitive to change, culturally
sensitive, low-burden, low-cost, built into standard procedures, and involve the patient.

Health care financing

Total health spending as a fraction of GDP

There are generally five primary methods of funding health care systems:

1. General taxation to the state, county or municipality

2. Social health insurance

3. Voluntary or private health insurance

4. Out-of-pocket payments

5. Donations to health charities

In most countries, there is a mix of all five models, but this varies across countries and over
time within countries. Aside from financing mechanisms, an important question should always
be how much to spend on health care. For the purposes of comparison, this is often expressed as
the percentage of GDP spent on health care. In OECD countries for every extra $1000 spent on
health care, life expectancy falls by 0.4 years. A similar correlation is seen from the analysis
carried out each year by Bloomberg. Clearly this kind of analysis is flawed in that life
expectancy is only one measure of a health system's performance, but equally, the notion that
more funding is better is not supported.

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 In 2011, the health care industry consumed an average of 9.3 percent of
the GDP or US$ 3,322 (PPP-adjusted) per capita across the 34 members of OECD countries. The
US (17.7%, or US$ PPP 8,508), the Netherlands (11.9%, 5,099), France (11.6%,
4,118), Germany (11.3%, 4,495), Canada (11.2%, 5669), and Switzerland (11%, 5,634) were the
top spenders, however life expectancy in total population at birth was highest in Switzerland
(82.8 years), Japan and Italy (82.7), Spain and Iceland (82.4), France (82.2) and Australia (82.0),
while OECD's average exceeds 80 years for the first time ever in 2011: 80.1 years, a gain of 10
years since 1970. The US (78.7 years) ranges only on place 26 among the 34 OECD member
countries, but has the highest costs by far. All OECD countries have achieved universal (or
almost universal) health coverage, except the US and Mexico.

In the United States, where around 18% of GDP is spent on health care, the Commonwealth

Fund analysis of spend and quality shows a clear correlation between worse quality and higher
spending.

Administration and regulation

The management and administration of health care is vital to the delivery of health care
services. In particular, the practice of health professionals and the operation of health care
institutions is typically regulated by national or state/provincial authorities through appropriate
regulatory bodies for purposes of quality assurance .Most countries have credentialing staff in
regulatory boards or health departments who document the certification or licensing of health
workers and their work history.

Health information technology

Health information technology (HIT) is "the application of information processing involving

both computer hardware and software that deals with the storage, retrieval, sharing, and use of
health care information, data, and knowledge for communication and decision making.

Health information technology components:

 Electronic Health Record (EHR) - An EHR contains a patient's comprehensive medical

history, and may include records from multiple providers

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  Electronic Medical Record (EMR) - An EMR contains the standard medical and clinical
data gathered in one's provider's office

 Personal Health Record (PHR) - A PHR is a patient's medical history that is maintained

privately, for personal use

 Medical Practice Management software (MPM) - is designed to streamline the day-to-day

tasks of operating a medical facility. Also known as practice management software or
practice management system (PMS).

 Health Information Exchange (HIE) - Health Information Exchange allows health care

professionals and patients to appropriately access and securely share a patient's vital
medical information electronically.

ADVANTAGE INDIA

Strong demand

*Healthcare market in India is expected to reach US$ 372 billion by 2022, driven by rising
income, better health awareness, lifestyle diseases and increasing access to insurance.

*As of 2021, the Indian healthcare sector is one of India’s largest employers, as it employs a
total of 4.7 million people.

Attractive opportunities

*In the Economic Survey of 2022, India’s public expenditure on healthcare stood at 2.1% of
GDP in 2021-22 against 1.8% in 2020-21.

*Two vaccines (Bharat Biotech's Covaxin and Oxford-AstraZeneca’s Covishield manufactured

by SII) were instrumental in medically safeguarding the Indian population against COVID-19

Rising manpower

*Availability of a large pool of well-trained medical professionals in the country.

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*The number of allopathic doctors with recognised medical qualifications (under the I.M.C Act)
registered with state medical councils/national medical council increased to 1.3 million in
November 2021, from 0.83 million in 2010.

Policy and government support

*In Union Budget 2022-23, Rs. 86,200.65 crore (US$ 11.28 billion) was allocated to the
Ministry of Health and Family Welfare (MoHFW).

*The Indian government is planning to introduce a credit incentive programme worth Rs. 500
billion (US$ 6.8 billion) to boost the country’s healthcare infrastructure.

INVESTMENTS/ DEVELOPMENTS

Between April 2000-March 2022, FDI inflows for drugs and pharmaceuticals sector stood at
US$ 19.41 billion, according to the data released by Department for Promotion of Industry and
Internal Trade (DPIIT). FDI inflows in sectors such as hospitals and diagnostic centres and
medical and surgical appliances stood at US$ 7.93 billion and US$ 2.41 billion, respectively.
Some of the recent developments in the Indian healthcare industry are as follows:

 As of August 23, 2022, more than 210.31 crore COVID-19 vaccine doses have been
administered across the country.

 As of August 8, 2022, India has exported 24.24 crore vaccine doses.

 In August 2022, Edelweiss General Insurance partnered with the Ministry of Health,
Government of India, to help Indians generate their Ayushman Bharat Health Account
(ABHA) number.

 The healthcare and pharmaceutical sector in India had M&A activity worth US$ 4.32
billion in the first half of 2022.

 As of July 2022, the number medical colleges in India stood at 612.

 In July 2022, the Indian Council of Medical Research (ICMR) released standard
treatment guidelines for 51 common illnesses across 11 specialties to assist doctors,

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 particularly in rural regions, in diagnosing, treating, or referring patients in time for
improved treatment outcomes.

 In July 2022, the National Pharmaceutical Pricing Authority (NPPA) fixed the retail
prices for 84 drug formulations, including those used for the treatment of diabetes,
headache, and high blood pressure.

 In March 2022, Hyderabad-based pharmaceutical company Biological E applied for

emergency use authorisation (EUA) for its Covid-19 vaccine Corbevax for the 5-12 year
age group.

 In January 2022, Phase 3 trials commenced of India's first intranasal vaccine against
COVID-19 that is being developed by Bharat Biotech, in conjunction with the
Washington University School of Medicine in St Louis, the US.

 Startup HealthifyMe, with a total user base of 30 million people, is adding half a million
new users every month and crossed US$ 40 million ARR in January 2022.

 The number of policies issued to women in FY21 stood at 93 lakh, with one out of every
three life insurance policies in FY21 sold to a woman.

 In December 2021, Eka Care became the first CoWIN-approved organization in India,
through which users could book their vaccination slot, download their certificate and
even create their Health IDs.

 As of November 18, 2021, 80,136 Ayushman Bharat-Health and Wellness Centres (AB-
HWCs) are operational in India.

 As of November 18, 2021, 638 e-Hospitals are established across India as part of the
central government's ‘Digital India’ initiative.

 In November 2021, Aster DM Healthcare announced that it is planning Rs. 900 crore
(US$ 120.97 million) capital expenditure over the next three years to expand its presence
in India, as it looks at increasing the share of revenue from the country to 40% of the total
revenue by 2025.

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  In September 2021, Russian-made COVID-19 vaccine, Sputnik Light received
permission for Phase 3 trials in India.

 In September 2021, Biocon Biologics Limited, a subsidiary of Biocon, announced a

strategic alliance with Serum Institute Life Sciences, a subsidiary of Serum Institute of
India (SII). The alliance is expected to strengthen India's position as a global vaccine and
biologics manufacturing powerhouse.

GOVERNMENT INITIATIVES

Some of the major initiatives taken by the Government of India to promote the Indian healthcare
industry are as follows:

 In the Union Budget 2022-23:

o Rs. 86,200.65 crore (US$ 11.28 billion) was allocated to the Ministry of Health
and Family Welfare (MoHFW).

o Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was allocated Rs. 10,000
crore (US$ 1.31 billion)

o Human Resources for Health and Medical Education was allotted Rs. 7,500 crore
(US$ 982.91 million).

o National Health Mission was allotted Rs. 37,000 crore (US$ 4.84 billion).

o Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was

allotted Rs. 6,412 crore (US$ 840.32 million).

o The Government of India approved continuation of ‘National Health Mission’

with a budget of Rs. 37,000 crore (US$ 4.85 billion).

o Rs. 5,156 crore (US$ 675.72 million) was allocated to the newly announced PM-
ABHIM to strengthen India’s health infrastructure and improve the country’s
primary, secondary and tertiary care services.

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 In July 2022, the World Bank approved a US$ 1 billion loan towards India's Pradhan
Mantri-Ayushman Bharat Health Infrastructure Mission.

 In May 2022, the Union Government approved grants for five new medical colleges in
Gujarat with a grant of Rs. 190 crore (US$ 23.78 million) each. These colleges will come
up in Navsari, Porbandar, Rajpipla, Godhra and Morbi.

 In November 2021, the Government of India, the Government of Meghalaya and the
World Bank signed a US$ 40-million health project for the state of Meghalaya. Project
will improve the quality of health services and strengthen the state’s capacity to handle
future health emergencies, including the COVID-19 pandemic.

 In September 2021, Prime Minister Mr. Narendra Modi launched the Ayushman Bharat
Digital Mission. The mission will connect the digital health solutions of hospitals across
the country with each other. Under this, every citizen will now get a digital health ID and
their health record will be digitally protected.

 In September 2021, the Telangana government, in a joint initiative with World Economic
Forum, NITI Aayog and HealthNet Global (Apollo Hospitals), launched ‘Medicine from
the Sky’ project. The project will pave the way for drone delivery of life saving
medicines and jabs in far-flung regions of the country.

 According to a spokesperson, the Indian government is planning to introduce a credit

incentive programme worth Rs. 500 billion (US$ 6.8 billion) to boost the country’s
healthcare infrastructure. The programme will allow firms to leverage the fund to expand
hospital capacity or medical supplies with the government acting as a guarantor and
strengthen COVID-19-related health infrastructure in smaller towns.

 In July 2021, the Ministry of Tourism established the ‘National Medical & Wellness
Tourism Board’ to promote the medical and wellness tourism in India.

 In July 2021, the Union Cabinet approved continuation of the National Ayush Mission,
responsible for the development of traditional medicines in India, as a centrally
sponsored scheme until 2026.

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  In July 2021, the Union Cabinet approved the MoU between India and Denmark on
cooperation in health and medicine. The agreement will focus on joint initiatives and
technology development in the health sector, with the aim of improving public health
status of the population of both countries.

 In June 2021, the Ministry of Health and Family Welfare, in partnership with UNICEF,
held a capacity building workshop for media professionals and health correspondents in
Northeastern states on the current COVID-19 situation in India, to bust myths regarding
COVID-19 vaccines & vaccination and reinforce the importance of COVID-19
Appropriate Behaviour (CAB).

Working towards building a healthier India

The Healthcare industry in India comprises of hospitals, medical devices, clinical trials,
outsourcing, telemedicine, medical tourism, health insurance, and medical equipment. The
industry is growing at a tremendous pace owing to its strengthening coverage, services and
increasing expenditure by public as well as private players.

Growing incidence of lifestyle diseases, rising demand for affordable healthcare delivery systems
due to the increasing healthcare costs, technological advancements, the emergence of
telemedicine, rapid health insurance penetration and government initiatives like e-health together
with tax benefits and incentives are driving the healthcare market in India.

 The Indian Healthtech industry was valued at $1.9bn in 2020. By 2023, it is expected to
reach $ 5B by 2023 at a CAGR of 39%

 The digital healthcare market in India was valued at INR 116.61 Bn in 2018, and is
estimated to reach INR 485.43 Bn by 2024, expanding at a compound annual growth rate
(CAGR) of ~27.41% during the 2019-2024 period

 By 2022, the diagnostics market is expected to grow at a CAGR of 20.4% to reach $32
bn from $5 bn in 2012

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  The Telemedicine market is the maximum potential eHealth segment in India, which is
expected to touch $5.4 Bn by 2025, growing at a compound annual growth rate (CAGR)
of 31%

 Over the next 10 years, National Digital Health Blueprint can unlock the incremental
economic value of over $200 bn for the healthcare industry in India

 India has the world’s largest Health Insurance Scheme (Ayushman Bharat) supported by
the government

 India’s comprehensive investment in Medical Education: INR 17,691.08 Cr invested in

157 new approved Medical Colleges since 2014

 Ayush sector has witnessed significant growth from $3 bn in 2014 to $18 bn in 2022

100% FDI is allowed under the automatic route for greenfield projects. For investments in
brownfield projects, up to 100% FDI is permitted under the government route.

CSR activities

 Corporate Social Responsibility (CSR) refers to the responsibility of the corporate or

business institution to work for the betterment of the society and people beyond their
staffs/workforce

 According to World Business Council for Sustainable Development (2000), Corporate

Social Responsibility can be defined as: “The continuing commitment by business to
behave ethically and contribute to economic Social development while improving the
quality of life of the workforce and their families as well as the local community and
society at large”

 It is an umbrella concept consisting of variety of strategies and actions undertaken by

private-for-profit agencies on a voluntary basis without any social, legal and economic
obligation but just with the positive intention to create and contribute positive changes in
different dimensions of society

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 It can be also understood as a contribution made by the business for the sustainable
development of the society, nation and globe

 CSR is a widely known concept in business institution and holds pretty long history of its
contribution to the society. However, it is neither too old nor too new concept in global
health as there are limited scientific literatures about CSR and health

 At present, rather than limiting CSR to only non-health corporate field, it’s time for
health related corporate sectors as well to expand their horizon in CSR and make the best
use of it for the goodness of people and their own too.

 Why CSR is in dire need in Health at present?

 Health is a global agenda and all human beings are in search of better health
status, thus demanding huge amount of technical and financial focus

 Global health issues are rapidly increasing and being more and more complicated.
On the other hand, global funding to act meticulously on these health issues to
reach up to the bottom of the society is limited.

 Also limited are other resources like manpower and technologies which can be
fulfilled by a strong partner like corporate society

 Health needs permanent attention while health resources are finite

 High time for establishing sustainable health care system all over the world

 To improve quality of life of people through addressing all the above mentioned
shortfalls

 CSR in health can be both sided i.e. from inside and outside the health sector. For e.g.:
either corporate hubs outside of health can contribute for the better health system and
better health facilities of the people or business institutions inside health sector can go
beyond their for profit objective and contribute to the society

 Health related corporate sectors include: hospitals, pharmaceutical industries, health

product manufacturers, health insurance companies etc.

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 Either for a health related or non-health related corporate sector, examples of some
scopes/opportunities for performing CSR in health are:

 Health promotion activities

 Health protection through manufacturing different health safety goods, complying

with occupational safety and health

 Allocation and distribution of resources for improving the social determinants of

health i.e. the places and conditions where we are born, live, grow, work and age

 Research and innovation

 Support in policy implementation

 Financial or work effort donation to health related charities etc.

 It may also sound confusing at first that how a corporate sector (private-for-profit) can
increase their benefit by contributing more for social benefit when they might be
themselves struggling hard to amplify their business and profit.

 Moreover, strict rules and regulations, expensive workforce, costly instruments and
maintaining high international standards may look as a limited opportunity to focus on
CSR. However, the benefits of getting involved in CSR in health for corporate agencies
are:

 Social acceptance from key stakeholders

 Reputation management and increased patient loyalty

 More attraction and retention of the employees

 Helps to attract more investors and other stakeholders

 Increases goodwill and raises high bar for competition to other competitors

 Support and recognition from government and international bodies

 Encourage innovation and enthusiasm

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  It may look like a big challenge about what sort of activity should be carried on under
CSR in health sector. Some of the examples that can be implemented as well as are also
currently executed in field as a part of CSR are:

 Financial and technological support and increasing affordability to reduce barriers

in health care access

 Going beyond medical care and focusing on integrated health care delivery
through inter-sectoral partnerships

 Addressing demand supply match in public health infrastructures

 Community partnerships on different health issues

 Supporting fund-raising activities

 Volunteering in health campaigns and organizing health camps

 Collaboration and coordination with and among different health institutions to act
mutually. E.g.: supporting Red Cross to act against epidemic and pandemic
disease

Manufacturing/selling drugs at low price for economically vulnerable population

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