India has always seen a drain of resources from smaller towns and cities to the metros. Whether these resources are electricity and water towards behemoths like Mumbai and Delhi at the cost of smaller towns and villages, or the exodus of people in search of their dreams because apparently big cities is where they lie, despite the astronomical rents and living costs, congested localities, noncompliant public transportation operators, long working hours, and unflattering salaries. Analysis of the Indian healthcare sector will offer a similar storyline, where the density of healthcare facilities in metros and larger cities is significantly more than that of smaller towns, semi-urban, and rural areas.

In fact, studies show that there is one government hospital bed for every 2046 people in India and only one state-run hospital for over 90,000 people. This number is more desperate in smaller towns and rural areas. If we take into account the number of private hospitals in India as well, the ratio improves to 1 bed per 879 people, still only a third of the global average. This ratio, however, is poorer in nonurban India at one bed for over 1000 people. This leads to a dearth of government doctors, with an appalling ratio of one for over 10,000 people. In fact, three fourths of the country’s doctors serve a fourth of India’s population residing in large cities.

The Indian healthcare sector analysis also shows that the expenditure on healthcare in terms of GDP in India is well below global standards, and lower than some of our less developed neighbors as well.

There is an opportunity to establish quality healthcare facilities and hospitals in tier2/tier 3 cities for several reasons, some of which have been illustrated below.

• While there has been talk of Ayushman Bharat leading to the creation of several hundred hospitals, the speed of development in the public sector is not India’s strong point despite recent promise in infrastructure development. Furthermore, a higher number of hospitals will be required to meet the increasing needs of a growing population. Private players have a great opportunity to address this gap either on their own or in partnerships with the government.
• Satellite centres established in semi urban and rural areas by hospital chains and other city hospitals only address part of the need. While these centres are equipped at a basic level, managed by local junior doctors and have consultants that travel to them regularly to address patient needs, primary and possibly secondary care is all that can be offered. Treatment of any other type would require patients to travel to larger hospitals in neighbouring cities, which is a very taxing on them and their pockets. Establishing quality tertiary care centres in these areas will allow people to have more wholesome access to healthcare
• This follows from the previous point. While telemedicine is slowly becoming a regular feature for several hospitals across the country, personal touch in healthcare is of paramount importance. Holistic healing involves more than just treating the ailment, and can be effective only with actual patient-doctor contact.
• There is a catastrophic shortage of doctors and nursing staff in non urban and semi urban India, and the small numbers that exist are under qualified. A WHO study reports that only one in five are qualified to practice medicine and up to 75% of primary care visits are performed by self proclaimed doctors. Having personally spoken to a few doctors in cities, I learned that they would be happy to go back to their home towns and practice if the facilities and remunerations would be competent. A lot of organizations in other industries are recognizing this and establishing centres in smaller towns to improve employee happiness and performance. This is also being supported by infrastructure development in these smaller towns. If better hospitals are established in small towns, we could see an influx of local doctors that return to serve patients there.
• Health and hygiene at hospitals in semi urban and rural India are highly questionable and one cannot be certain if they cure diseases or add to the burden. Standard medical care needs to be established in these areas, which will only occur when serious players from the cities, with their level of professionalism decide to expand their footprints into ‘greener’ pastures.
• A first mover advantage coupled with robust management and affordable quality care could lead to a healthy business proposition.
• The need to serve and provide quality healthcare needs to also be one of the primary motives of hospitals and if done at sustainable levels, it’s a win-win for all.