Healing Indian healthcare

The Indian healthcare system is often criticised for inadequate public expenditure, persistent inequities, and excessive dependence on private providers. Comparatively less attention has been paid to healthcare management: the organisation of services, leadership, institutional processes, human resource management, and operational efficiency. In this context, Tilak Shankar’s Management of Healthcare in India: Need for a Paradigm Shift is both timely and valuable. The book argues that many of India’s healthcare challenges stem not just from resource deficits but from systemic management and governance failures. It makes a convincing case for professionalisation, leadership development, evidence-based decision-making, and broader management reform in Indian healthcare.Shankar’s central claim is that India’s health system suffers from pervasive managerial shortcomings. Public facilities frequently struggle with inefficient patient flows, poor utilisation of infrastructure, fragmented decision-making, and weak accountability mechanisms. Even where resources exist, they are rarely deployed optimally. The author’s emphasis on management science, systems thinking, and institutional leadership fills a major gap in health systems discourse, though it also raises certain larger questions which are outlined below.The book is structured into four broad parts. Part I examines the public sector, tribal healthcare, and non-profit hospitals. Part II focusses on operational aspects of healthcare management, including leadership, management science, marketing, human resources, quality assurance, and technology. Part III addresses financing issues, particularly corporate hospital management and the growing role of private equity and capital markets. Part IV discusses public health reforms and future trends in healthcare.Part I (which has a chapter by Sudharshini Subramaniam) provides a useful overview of the structural diversity and fragmentation of Indian healthcare. The discussion of public health services revisits familiar challenges: bureaucratic rigidity, understaffing, inadequate responsiveness, and inefficient resource utilisation. The chapter on tribal healthcare (written by Shailendra Kumar B. Hegde and Pritha Venkatachalam) perceptively shows the limitations of standardised service delivery models in marginalised contexts, emphasising the need for contextual adaptation and community engagement. The chapter on non-profit hospitals is particularly valuable because this sector plays a unique role in delivering affordable and socially responsive healthcare, yet receives little attention in healthcare management literature. The author argues that sound governance, strategic planning and management, and cross-subsidisation are essential for non-profit institutions to remain viable. The case study of the Sundaram Medical Foundation effectively illustrates how professional management can advance a non-profit hospital’s social mission.Management of Healthcare in India: Need for a Paradigm ShiftBy Tilak ShankarRoutledgePages: 390Price: Rs.1,595Part II forms the managerial core of the volume and offers what is perhaps its most distinctive contribution. The scope and depth of these chapters are difficult to summarise in a review and merit careful reading in full. The chapters on leadership, management science, quality, and support services collectively argue that healthcare is a complex service system requiring specialised management competencies. However, the chapter on marketing adopts a largely business-oriented perspective, neglecting prevalent unethical practices—such as referral commissions (“cuts”) and aggressive advertising by corporate hospitals—which drive supplier-induced demand and medically unnecessary procedures.This gap is striking because medical ethics has long recognised the dangers of unethical marketing, and under ethics codes, individual medical practitioners in India are prohibited from advertising. The chapter on human resources is sharply analytical, arguing that staffing crises stem largely from regional maldistribution, poor motivation, and dead-end career tracks. It calls for strategic workforce planning, leadership development, and robust performance management.The growing role of private capitalPart III is arguably the book’s most compelling section, dealing with healthcare financing and the growing role of private capital. Chapter 14, which focusses on private equity and initial public offerings in healthcare, rightly identifies healthcare as an increasingly attractive investment destination and explains how private equity has fuelled the expansion of hospital chains .At the same time, in effect it exposes certain contradictions of healthcare financialisation and problems related to private equity investment, which is fundamentally driven by high, rapid financial returns.

This book argues that many of India’s healthcare challenges stem not just from resource deficits but from systemic management and governance failures.  | Photo Credit: By Special Arrangement As the chapter shows, these investments demand rapid expansion, higher revenues, and inflated profitability to facilitate quick investor exits. Such pressures encourage growth in high-margin tertiary and quaternary services, aggressive market expansion, undue promotion of medical procedures, and a misplaced emphasis on commercially lucrative specialties, escalating costs while reinforcing inequalities in access to care. The chapter opens up a larger debate about the nature of healthcare itself. Should healthcare be treated as an investment asset, a site for financial accumulation, or as a social institution governed by principles of equity and human need?Likewise, Part IV merits close attention. Chapter 15 appropriately argues for more efficient public health operations, with proposed reforms focussing largely at the managerial level, such as administrative improvements, greater efficiency, and better coordination. While these are necessary and desirable, the challenges facing India’s public health system extend far beyond managerial deficits. It is important to also address the determinants of weak management such as underfunding and understaffing of public facilities, overload of responsibilities on inadequate number of administrators, over-centralised decision-making, political interference and patronage, and perverse power hierarchies. In such circumstances, promotion of managerial reforms remains important, but needs to be cognizant of the fact that the larger system might be structured in ways that make good management extremely difficult, unrewarded or constrained.Similarly, Chapter 16 outlines future trends, including digital health, insurance expansion, and the continuing growth of corporate healthcare. These developments are indeed shaping contemporary healthcare landscapes, but they also pose questions that require deeper analysis beyond managerial frameworks. The rapid expansion of insurance-based financing, increasing corporatisation of service delivery, and the growing influence of financial investors have fundamentally altered the organisation and logic of healthcare systems in India today, reflecting in policy and political-economic decisions.The book’s subtitle therefore invites some contemplation. The reforms advocated throughout the volume undoubtedly represent an important shift in management thinking, but managerial reforms alone do not constitute the paradigm shift that India’s healthcare system urgently requires. In fact, the problems confronting Indian healthcare are not solely administrative; they are also deeply political, economic, and structural.A genuine paradigm shift in Indian healthcare would require substantially increased public investment in health, revitalisation of public provisioning systems, stricter regulatory frameworks for private healthcare providers, and policies to contain excessive commercialisation and corporate oligopolies in healthcare. This shift would also require institutionalising patients’ rights and strengthening community participation and participatory governance mechanisms. While management reforms within institutions can undoubtedly improve organisational efficiency, they cannot themselves resolve broader problems arising from underfunded public health systems or the growing dominance of corporate and financial interests in healthcare.Overall, Shankar’s scholarly book makes an important contribution by framing management as an indispensable component of health systems reform in India. Even readers who may have differing opinions about some of the details will find much to appreciate because of the emphasis on professional management, leadership, and systems thinking. The challenge for India is not to choose between managerial reform and structural transformation but to integrate managerial improvements within a broader healthcare reform agenda that strengthens public provisioning, effectively regulates private healthcare, curbs excessive commercialisation, and ensures equitable, affordable, quality healthcare for all. Dr Abhay Shukla is a public health professional and national co-convenor of the Jan Swasthya Abhiyan (People’s Health Movement – India).Also Read | Healthcare, bought and soldAlso Read | Rebuilding a politics of care