For Whom & At What Cost?
Whereas the medical fraternity in the country is going all out to woo the rich Western tourists, offering “state-of-the-art” world class equipment and expertise using minimally invasive techniques—there are still many Indians who have to make do without even the basic health services
By Neeraj Mahajan
When it comes to delivery of healthcare services, India has been living on the verge of a paradox. Whereas on one side the country has the best of doctors and facilities for heart surgery, neurosurgery, joint replacement --there are not many people who can afford it. The result is appalling disparity between the wealthy, who can afford expensive, quality care, and the poor, whose access to health care is spotty or simply nonexistent.
Though the government manages a vast network of massive hospitals, very few government-run hospitals are known for any quality work.
India trains the highest number of doctors in the world—almost twice the number in USA which trains only 15,000 a year. Even this is soon going to increase from 32,000 to over 50,000-60,000. We train the largest number of nurses and medical technicians. And have the largest number of USFDA-approved drug manufacturing units outside the US. Ideally all this should have been sufficient to create the foundation for an extraordinary healthcare delivery system but the irony is that the people do not have cash to pay for it.
Even as income levels have risen, cost of healthcare has steeply spiraled upwards. The result is that a majority of the masses still cannot afford good quality healthcare. The question is “What percentage of people can afford it and how many people have access to it?”
Approximately two fifths of hospital inpatients have to borrow money or sell assets to finance the treatment of their near and dear ones. And a quarter of farmers and poor people are driven below the poverty line to fund their medical care.
At this stage three things need to be focused … one -- diseases are getting highly mobile. Two-in today’s shrinking and mobile - global village - nothing – not even disease is a country or persons personal problem. A new infection may start from the slums of Calcutta in the morning and but could affect people in New Delhi or New York by the evening and become a nightmare for Canada or China by the weekend.
And last but not the least there is no such thing as amir aadmi ki bimari, garib aadmi ki bimari (rich man’s disease or poor man’s disease). No matter how clean you may keep your home, how many times you may wash your hands with the best disinfectant available in the market or visit the most expensive doctor—a disease or virus does not necessarily differentiate between the rich or the poor or come visiting after checking the person’s social status or address.
This obviously means that even after getting the immunizations shots—we all are as vulnerable to death and disease if our surroundings are not clean. Our homes may be clean but the vectors of the disease can breed in the slums and jhuggi jhompri clusters. And even if the maid servant who comes to our house is infected … disease can enter our homes. This obviously means that even though we have done everything to keep ourselves disease free, we still cannot be totally immune from the risk of catching the infection till the last man on the street from the carpenter, barber to the begger on the street corner too is disease free.
“No system anywhere in the world, healthcare or otherwise can afford to ignore the needs of the people for whom it is designed. Patients can wait but disease…pain & suffering doesn’t…” says Sanjay Vishwakarma who works for a multinational company. “Just like justice delayed is justice denied, healthcare delayed is as good as opportunities lost as nothing damaged in the body can be made to work better than the original. Even human body’s spare parts are not easily available…” he adds.
Almost 100 years after the first heart surgery was performed only 8% of the world’s population can afford a heart surgery. India requires around 2.5 million heart surgeries a year, yet all the heart hospitals in India put together do only around 80,000 surgeries a year.
The reason for the rise in cost is -- more technology. Twenty years ago if somebody had chest pain, very few centers were doing angioplasty and very few operations were done. Today we operate upon anything that can move. And before the operation there are 25 different tests we perform, each costing Rs 5,000-10,000. This increases the safety of the operation, but increases the price.
According to World Health Organisation (WHO) statistics India has a national average of only 45 doctors and 8.9 beds for every 100,000 patients. India ranks 127 out of the 177 countries in the Human Development Index. A huge chunk of the cost of healthcare is accounted for by drugs and medicines. According to the Data from the National Sample Survey over 12 per cent of household non-food consumption expenditure goes into paying for healthcare. About 82% of the healthcare expenditure comes as ‘out of pocket payments’ by the people making the Indian public health system grossly inadequate and under-funded.
Inequality in access to healthcare is one reason why India contributes more deaths than any other country to the global figure of 500,000 women and girls dying from pregnancy, childbirth or unsafe abortion each year. India is responsible for a quarter of these maternal deaths, which are preventable. One in every 70 Indian girls die during pregnancy, childbirth or unsafe abortion. Routine emergency obstetric care procedures, such as blood transfusions and Caesarean sections, are far beyond the reach of many poor women.
Uttar Pradesh one of the poorest states in India has 583 fewer community health centers as against 1,097 required by Indian public health standards. One third of these centers have an obstetrician or gynecologist, while about 45 percent do not have funds to operate even a single ambulance. The ratio of hospital beds to population in rural areas is fifteen times lower than that for urban areas. The ratio of doctors to population in rural areas is almost six times lower than that in the urban population.
The most peripheral and most vital unit of India’s public health infrastructure is a primary health centre (PHC). In a recent survey it was noticed that only 38% of all PHCs have the essential manpower and only 31% have all the essential supplies.
The Infant Mortality Rate in the poorest 20% of the population is 2.5 times higher than that in the richest 20% of the population. In other words, an infant born in a poor family is two and half times more likely to die in infancy, than an infant in a better off family. A child in the ‘Low standard of living’ economic group is almost four times more likely to die in childhood than a child in the ‘High standard of living’ group. Female child is 1.5 times more likely to die before reaching her fifth birthday as compared to a male child.
To fill in this void many drug companies and big businesses have begun to dominate the private health sector, with five-star hospitals providing services which "only foreigners and the richest Indians can afford". These are largely unregulated, with no standardisation of quality or costs.
The growth of private healthcare sector has skewed the balance towards urban-centric tertiary health services with profitability overriding equality. As a result of this the number of people who could not seek medical care because of lack of money has increased significantly. The proportion of people unable to afford basic healthcare has doubled in last decade.
In the absence of an effective regulatory authority over the private healthcare sector the quality of medical care is constantly deteriorating. Powerful medical lobbies prevent government from formulating effective legislation or enforcing the existing ones.
A recent World Bank report acknowledges the facts that doctors over-prescribe drugs, recommend unnecessary investigations and treatment and fail to provide appropriate information for patients even in private healthcare sector. The same report also states the relation between quality and price that exists in the private healthcare system. The services offered at a very high price are excellent but are unaffordable for a common man.