Restructuring Social Services

Our neighbourhood doctor would charge Rs 20 perhaps for a consultation on piles, and recommend a medicine worth another Rs 20. How does Dr D R Singh charge 10 times as much? He ministers to the populous poor district of Trilokpuri; it can be argued that he is charging more because his patients are less tolerable. But he can charge more because he faces less competition. So it happens that my driver pays far more for health care than I do.

So does he for education. His children go to a government school where the teacher just sits and knits. So he employs a teacher after school to give private tuition, which costs him Rs 400 a month.

 

Contrast this with America. There, medical insurance is paid for by employers; for those who are not employed, the government runs medicaid. Since under both arrangements, consultations are free, Americans go freely for consultations. They visit emergency stations of hospitals 90 million times a year; but half of their visits are for trifling complaints like sprains and coughs. Both the government and private employers have been trying to cut down costs by looking for medical care providers who would charge less. Cost-cutting in the industry has led to a restructuring of the industry: smaller hospitals and practices have been closing down or been taken over by medical service providers who own hospitals, doctors practices, clinics etc, across the country. They have pioneered a new business the phone triage business, described recently by George Anders in the Wall Street Journal.

In this business, a hundred or more experienced nurses sit in an open hall, separated by low partitions. Each has a telephone. People with medical problems phone in. The nurse who takes a call asks about the symptoms, and enters them in a computer terminal before them. The computer gives her questions to ask. The answers narrow down the diagnosis. On the basis of the diagnosis, the nurse tells the person to apply a certain medical treatment or to go to a particular doctor or hospital close to him. She enters the case and the treatment she recommends into the computer. The computer can generate statistics. In the case of one centre it showed that in 40 per cent of the cases, the callers were told how to treat themselves without any outside help. In 40 per cent of the cases they were directed to a doctor. Only in 2 per cent of the cases were they told to go to emergency services.

Quality and cost control are applied to this business in two ways. Supervisors can listen in to the conversation of any nurse and check her responses. And they can compare her recommendations over a certain period with the average; if she recommends going to emergency or to a doctor far more often or less often than the average, then her performance is reviewed.

In the phone-triage businesses, the computer mimics a doctor. It tells the nurse to ask questions that a doctor would ask in the circumstances. It follows a certain sequence: it starts with more serious possibilities and goes on to less serious ones. However, a computer is not subject to the moral hazards of a doctor. It has no incentive to overmedicate or overcharge. Its competence does not vary; although the nurses may, it is subject to statistical and personal checks. The computer cannot get drunk, or have a fight with its wife, or develop a drug addiction. In other words, it is a more reliable medicator as long as it knows its limits and refers the caller to a doctor or a hospital whenever necessary.

Whereas, in health care, the concern in the US is to cut costs, the concern in education is to raise quality. The US has compulsory elementary education; but the quality of the education is much poorer than in Europe, leave alone East Asia. Many youths leave school basically illiterate and uneducated. In addition to which there is the problem of school-centred risks: a child may pick up a drug habit there, may join a criminal gang, may get killed by the gun of a school kid. So there is a strong demand for allowing choice in education, and for letting non-government schools to come up which are not expensive. American schoolteachers are unionised, and resist privatisation of schools. But some states have licensed what are called charter schools. A number of people may get together and decide to provide alternative education which does not fit into the standard curriculum of government schools; but if its teaching programme meets certain minimum conditions, the school is given a charter and can take any

students who want to go to it. The subsidy that the state or the local authority would have given to a government school in respect of a student is passed on to the charter school. Usually, groups of concerned parents who have strong views about how their children should be educated get together and set up charter schools. In this way charter schools encourage experimentation, although they do not necessarily promote excellence.

Why can we not make similar experiments in India? It will be decades before there are enough doctors in India; and even then there will always be incompetent or avaricious doctors like Dr Singh. Why cannot someone make up a computer programme to provide standard remedies for the majority of ailments? Why cannot children be taught with video cassettes, instead of knitting teachers? We could choose the best teachers in the country and get their lessons recorded on video cassettes. People I talk to consider these ideas subversive. Doctors have five years training; how can we allow untrained people to take their place? If video cassettes are used to teach, what will happen to teachers? But our standards of living will never improve unless costs are reduced and quality raised by competition; and medical computer software and educational video cassettes are competition. We cannot believe in competition for our industry and not for our health and education providers.