Dealing with Inequalities: What Can We Learn from the Indian Healthcare System? "Presentation" - Vedang Murthy
November 15, 2024
At the 2024 Advanced Prostate Cancer Consensus Conference (APCCC), Vedang Murthy explores cost-efficiency strategies in India's healthcare system. The presentation highlights innovative approaches including equipment indigenization and simplified radiation protocols while emphasizing the concept of "jugaad" - making optimal use of available resources - as a guiding principle for delivering effective cancer care in resource-constrained settings.
Biographies:
Vedang Murthy, MD, DNB, DipEPP, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
Biographies:
Vedang Murthy, MD, DNB, DipEPP, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
Read the Full Video Transcript
Vedang Murthy: What can we learn from the Indian healthcare system? Actually, the answer lies on the last slide, but I won't go there because then it will not give me a chance to beat the cowbell. I'll start talking about cows.
This kind of in-your-face inequality is very common in LMICs, including India. But every healthcare system, every country, has more subtle manifestations of inequality. The question is, what are we going to do about it? We have a four-tiered network of public and private hospitals. But let me give you two facts. Only a quarter of our population has health cover. And a whopping 60% of the total health expenditure is out-of-pocket, which is way above the global mark or what is desirable.
This brings me to another very important fact, to put it in context: doctors and oncologists make major treatment decisions for patients. They are, in fact, even expected to take these decisions for the patients. And although we have been talking about shared decision-making in almost every talk, that is less common than you may think. If I give a patient three options with five different sequences of treatment, they're going to look at me all funny—what is this guy? He doesn't know what he's talking about.
So while the patients are thinking about their cancer control, and logistics, and travel to the hospital, we are worrying about what is essential for treatment, what is avoidable, and what is actually critical to drive the costs down. This brings me to the central theme of my talk—cost efficiency, which can be done in many ways. And I'll give you some examples related to prostate cancer as we go along.
Indigenisation has been a great part of our cost efficiency. A tele-cobalt machine, at a fraction of the cost of a linear accelerator, is excellent for palliation. We've also found local solutions for radiotherapy accessories, including 3D printing technology, which is not just reverse engineering. We have adapted them to Indian patients' anatomy, and this is a huge cost saving because this is a recurring cost for a lot of patients undergoing radiotherapy.
Our surgeons have a new toy. It is a robot called the SSI Mantra, and it is going through its paces. It's already available in the Indian market. It may be available soon in the West as well. And a rough estimate of the installation and running cost, as compared to the existing market standard, is about a third—huge cost saving, again, for the healthcare system and for the patients.
Now this is the interesting part. How do we indigenise systemic therapy? Well, in other words, it's called generics. It has received some negative media attention, sometimes justified because there are some bad apples in the basket, so to say. But this forms the backbone of driving the cost down, and we rely on this heavily. Can we do something about choosing the right generics? So this is a multi-step framework for choosing these generics, which we have adopted in our hospital. It includes checklists for assessing the robustness of the company that is making it, a technical assessment of the drug, and a financial analysis. Only the top two or three make it to the hospital pharmacy.
Using this approach, this is a small study that one of my colleagues did, very recently published: 10 patients using the innovator, about 100 using the generic abiraterone. We looked at some simple clinical endpoints like PSA nadir time and rPFS. And reassuringly, we are not getting it completely wrong by using these generics. So this is very reassuring for us.
Coming to reduce. And what better than to reduce the dose of abiraterone, ably guided by this certain indophile that we all know in this forum? This is a survey of Indian oncologists, and a large majority of them have already changed, or are happy to change, to 250 milligrams after food of abiraterone. And this can have huge potential savings, not only in India but everywhere in the world.
India is a large country geographically, and patients find it difficult to travel to the hospital. So this is the Tata Memorial Center Hub and Spoke Model. The main center in Mumbai provides infrastructural, administrative, and financial support to smaller centers around the country, which, over time, develop and become hubs themselves for other smaller centers. So if the patient can't go to the hospital, the hospital goes to the patient.
Now moving to reduce and simplify. We, radiation oncologists, love our bells and whistles. We have a lot of technology. We have a lot of gadgets. And when we do SBRT with all this stuff, it looks like the patient is ready to be launched into space. A lot of our patients and our health systems cannot afford this. So is there a way of doing things much more simply?
Well, we have put in a lot of effort into standardizing simulation, planning, and delivery of treatment with good image guidance, all of which come for free. And we do SBRT in a much more simple way, and we get good results. Now somebody may question that this causes more toxicity, but hold on. This is the interim analysis of the randomized trial that we're doing, looking at five-fraction SBRT in high-risk versus five weeks of treatment. And the grade 3 toxicity is just 1% using this kind of SBRT. Again, very reassuring for us.
Replace. What better than to replace ADT with an orchidectomy for metastatic patients and use all the money that is saved for life-prolonging treatment? Apparently, 58% of us believe it should be called RP. And I did a quick survey of uro-oncologists—60% to 80% offer orchidectomy for metastatic patients. And most interestingly, about 50% of the patients accept it. Again, a huge saving for patients.
Finally, we often get only one chance to get things right, which is the first treatment. So we lean towards overtreatment. Now, again, somebody may raise an eyebrow: is that all right? Let's see if the patients accept it. This is an informed consent form, a snapshot, which clearly says from the trial that if you have the five-fraction treatment, the side effects may be more. And we asked them, if you are given a choice, which one will you accept? Of course, they don't have a choice—it's randomized—but a whopping 92% said they would still want SBRT because it is so convenient.
Which brings me to the last slide. This is a very intriguing Hindi word called "jugaad." Basically, in simple words, the rough translation is making the best of what you have from the resources that you have. And if you have to take away one thing, it would be using this kind of approach, which is both frugal and flexible while being inclusive. Thank you.
Vedang Murthy: What can we learn from the Indian healthcare system? Actually, the answer lies on the last slide, but I won't go there because then it will not give me a chance to beat the cowbell. I'll start talking about cows.
This kind of in-your-face inequality is very common in LMICs, including India. But every healthcare system, every country, has more subtle manifestations of inequality. The question is, what are we going to do about it? We have a four-tiered network of public and private hospitals. But let me give you two facts. Only a quarter of our population has health cover. And a whopping 60% of the total health expenditure is out-of-pocket, which is way above the global mark or what is desirable.
This brings me to another very important fact, to put it in context: doctors and oncologists make major treatment decisions for patients. They are, in fact, even expected to take these decisions for the patients. And although we have been talking about shared decision-making in almost every talk, that is less common than you may think. If I give a patient three options with five different sequences of treatment, they're going to look at me all funny—what is this guy? He doesn't know what he's talking about.
So while the patients are thinking about their cancer control, and logistics, and travel to the hospital, we are worrying about what is essential for treatment, what is avoidable, and what is actually critical to drive the costs down. This brings me to the central theme of my talk—cost efficiency, which can be done in many ways. And I'll give you some examples related to prostate cancer as we go along.
Indigenisation has been a great part of our cost efficiency. A tele-cobalt machine, at a fraction of the cost of a linear accelerator, is excellent for palliation. We've also found local solutions for radiotherapy accessories, including 3D printing technology, which is not just reverse engineering. We have adapted them to Indian patients' anatomy, and this is a huge cost saving because this is a recurring cost for a lot of patients undergoing radiotherapy.
Our surgeons have a new toy. It is a robot called the SSI Mantra, and it is going through its paces. It's already available in the Indian market. It may be available soon in the West as well. And a rough estimate of the installation and running cost, as compared to the existing market standard, is about a third—huge cost saving, again, for the healthcare system and for the patients.
Now this is the interesting part. How do we indigenise systemic therapy? Well, in other words, it's called generics. It has received some negative media attention, sometimes justified because there are some bad apples in the basket, so to say. But this forms the backbone of driving the cost down, and we rely on this heavily. Can we do something about choosing the right generics? So this is a multi-step framework for choosing these generics, which we have adopted in our hospital. It includes checklists for assessing the robustness of the company that is making it, a technical assessment of the drug, and a financial analysis. Only the top two or three make it to the hospital pharmacy.
Using this approach, this is a small study that one of my colleagues did, very recently published: 10 patients using the innovator, about 100 using the generic abiraterone. We looked at some simple clinical endpoints like PSA nadir time and rPFS. And reassuringly, we are not getting it completely wrong by using these generics. So this is very reassuring for us.
Coming to reduce. And what better than to reduce the dose of abiraterone, ably guided by this certain indophile that we all know in this forum? This is a survey of Indian oncologists, and a large majority of them have already changed, or are happy to change, to 250 milligrams after food of abiraterone. And this can have huge potential savings, not only in India but everywhere in the world.
India is a large country geographically, and patients find it difficult to travel to the hospital. So this is the Tata Memorial Center Hub and Spoke Model. The main center in Mumbai provides infrastructural, administrative, and financial support to smaller centers around the country, which, over time, develop and become hubs themselves for other smaller centers. So if the patient can't go to the hospital, the hospital goes to the patient.
Now moving to reduce and simplify. We, radiation oncologists, love our bells and whistles. We have a lot of technology. We have a lot of gadgets. And when we do SBRT with all this stuff, it looks like the patient is ready to be launched into space. A lot of our patients and our health systems cannot afford this. So is there a way of doing things much more simply?
Well, we have put in a lot of effort into standardizing simulation, planning, and delivery of treatment with good image guidance, all of which come for free. And we do SBRT in a much more simple way, and we get good results. Now somebody may question that this causes more toxicity, but hold on. This is the interim analysis of the randomized trial that we're doing, looking at five-fraction SBRT in high-risk versus five weeks of treatment. And the grade 3 toxicity is just 1% using this kind of SBRT. Again, very reassuring for us.
Replace. What better than to replace ADT with an orchidectomy for metastatic patients and use all the money that is saved for life-prolonging treatment? Apparently, 58% of us believe it should be called RP. And I did a quick survey of uro-oncologists—60% to 80% offer orchidectomy for metastatic patients. And most interestingly, about 50% of the patients accept it. Again, a huge saving for patients.
Finally, we often get only one chance to get things right, which is the first treatment. So we lean towards overtreatment. Now, again, somebody may raise an eyebrow: is that all right? Let's see if the patients accept it. This is an informed consent form, a snapshot, which clearly says from the trial that if you have the five-fraction treatment, the side effects may be more. And we asked them, if you are given a choice, which one will you accept? Of course, they don't have a choice—it's randomized—but a whopping 92% said they would still want SBRT because it is so convenient.
Which brings me to the last slide. This is a very intriguing Hindi word called "jugaad." Basically, in simple words, the rough translation is making the best of what you have from the resources that you have. And if you have to take away one thing, it would be using this kind of approach, which is both frugal and flexible while being inclusive. Thank you.