Diagnosing An Ailing Republic
Affair of the states
India is taking firm steps to a certain health disaster. All of 80 per cent of healthcare is now privatised and caters to a minuscule, privileged section. The metros are better off: they have at least a few excellent public health facilities, crowded though they might be. Tier II and III towns mostly have no public healthcare to speak of. As the government sector retreats, the private booms. In villages, if you are poor and sick, no one really cares, even if the government pretends to. You go to the untrained village “doctor”; you pray, you get better perhaps; all too often, you die of something curable. “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist,” Amartya Sen said recently in Calcutta. “It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”
Sadly, even the few initiatives the Indian state takes are badly implemented. Hear the story of Suresh, 45, who lost his younger sister to cancer, eight months ago. He’s a guard at the guesthouse of a pharmaceutical company in Mumbai and could not afford her treatment, so he sold some ancestral farmland in Gujarat. That money covered but a few months of bills from a private hospital. He then turned to a government hospital, but it didn’t have cancer care. It didn’t help in any way for Suresh that he worked for a pharmaceutical company: his job didn’t come with medical benefits. “We brought her back home, hoping that if we saved on the hospital bills, we would be able to buy her medication. Finally, the money I had was too little to provide her basic help. Maybe if I had been able to buy her medicines, she would have been alive today.”
But the state could have ensured that Suresh’s sister lived had he been able to utilise the ambitious health insurance scheme announced in Maharashtra in 1997. The Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) is on paper supposed to provide for 972 surgeries, therapies or procedures, along with 121 follow-up packages in 30 specialised categories. It provides each family coverage of up to Rs 1.5 lakh in hospitalisation charges at empanelled hospitals. It even allows for treatment at private hospitals. But poor implementation has ensured Suresh and hundreds of families like his do not know of such a scheme. This is true of other schemes across the country too.
Photograph by Vivek Pateria
Bhopal At the Sultaniya Hospital, as at many hospitals in the Hindi belt, there just isn’t enough space for the patients who turn up. Those who attend on patients routinely brave the open.
Meanwhile, health statistics are terrifying. More than 40,000 people die every year of mosquito-borne diseases, which are easily preventable; a maternity death takes place every 10 minutes; every year, 1.8 million children (below 5 years of age) die of preventable diseases. “We are the only country in the world with such a huge percentage of privatised healthcare. Recent estimates suggest that approximately 39 million people are being pushed into poverty because of high out-of-pocket expenses on healthcare. In 1993-94, the figure was 26 million people,” says Dr Shakhtivel Selvaraj, a health economist.
So the state’s pretence of reaching out to the poor is really quite a farce. Consider what’s been happening between the Planning Commission and health ministry. In November, the battle between then health minister Ghulam Nabi Azad and the Planning Commission came to light: Azad had pressed for increased spending on the public sector while the commission was intent on increasing private participation. This was a telling comment on the priorities of the UPA government. But with the 2014 elections in view, the government would like to present “health reforms” as a political tool. A framework for “universal health for all” is expected by April this year.
Barely 100 km from the national capital, the Kosi Kalan district of Uttar Pradesh, near Mathura, presents a pathetic picture of community health care. Four months ago, the primary health centre, which caters to more than 50,000 patients with two trained nurses and two doctors, was upgraded into a community health centre with a new building. However, doctors haven’t been posted at the new centre. Says Rajkumar, a doctor at the primary health centre, “We got the new building about four months ago. We are waiting for administrative sanctions”
Photograph by Tribhuvan Tiwari
Gurgaon Subedar Gupta (right) has spent about Rs 30,000 at private hospitals for his wife’s treatment in one month. He feels the hospitals have made her undergo unnecessary tests.
It’s a familiar tale of rural India. But what is also significant is that in the post-liberalisation era, the government health sector has virtually vanished from Tier II and III urban centres. Subedar Gupta, 32-year-old commercial vehicle driver from Gurgaon, has discovered that the government sector is an empty shell. It’s the private sector that has fleeced him. His wife Chanda Devi has been complaining of severe bodyache, itching and weakness for the last five years and no one knows why. Gupta spent about Rs 30,000 last month at private hospitals. He is now broke. “They ask us for same tests—blood test, X-rays and ecg. She is continuously on medicines. They are sucking all the money out of us.”
A large number of swanky hospitals and clinics have come up in urban India. But that does not ensure good care. There is also the issue of all this being loaded in favour of a profit-seeking system. Take the Rashtriya Swastha Bima Yojna, a government-supported health insurance scheme that rides on the private sector to provide medical care and surgical procedures at predetermined rates. Experts point to the dangers of induced demand and the prescription of unnecessary procedures to claim insurance benefits. Besides, the technology at private centres is often used to fleece patients rather than help them.
Dr Subhash Salunke, former director-general of health services, Goa, and currently director of the Public Health Federation of India, says the private sector is very scattered and unregulated, leading to lot of malpractices. This could have been checked to some extent had rules of the Clinical Establishment Act, 2010, been framed and implemented. Two years after the legislation was passed by Parliament, it hasn’t been implemented. The problem lies with the “stiff resistance from the private sector to the laying down of guidelines”.
Photograph by Sandipan Chatterjee
Calcutta Nomita Pramanik, a domestic help, has asthma. She earns Rs 2,800. A hospital visit costs Rs 250-300. She calls free treatment at government hospitals a “curse even enemies shouldn’t suffer”.
The health sector is also crippled by a shortage of doctors and nurses (see graphic). So when the government says it is serious about training more doctors and nurses, by setting up six new AIIMSes, it makes for sound planning. But politics quickly shows up: one of the AIIMSes is planned in Sonia Gandhi’s constituency, Rae Bareli. Many doctors trained in excellent government medical colleges swiftly move to the private sector; they are even reluctant to take up rural jobs or postings. “Of the 1,400 doctors appointed after a proper selection process, only 900 joined the service,” disclosed a spokesman of the Uttar Pradesh health directorate. Because of the shortage of doctors in government hospitals, the National Rural Health Mission (NRHM) had started to recruit those trained in the Ayurvedic, Unani, Siddha and homoeopathic streams, but the process was stalled by a Rs 5,000 crore scam.
So the poor continue to suffer. In a general ward of Krishnanagar Hospital in Nandia District, West Bengal, members of a patient’s family say that not a single doctor checked their ward for 24 hours after he was admitted with a cerebral condition. The doctor assigned to the hospital, who was in his chambers some 10 km away, had this to say when tracked down by Outlook, “I’m the only doctor for close to 500 patients. Is it possible for me to visit each and every patient? You have to understand my constraints. There is very little monetary incentive for doctors working in the rural areas. These are punishment postings. No one wants to come here. They want to work with rich patients and earn big money.”
As he spoke, there were close to 100 patients waiting in the visiting room to see him. They were all from the villages and small towns in Nandia district. Krishnanagar Hospital is the main district hospital and patients from all over Nadia are referred to this hospital. In Uttar Pradesh, modern private health services have yet to reach beyond a dozen key cities. The rest of the state has to depend on these 12 cities, a handful of which have facilities for tertiary care. Some facilities are available only in Lucknow, where the government has concentrated all the healthcare while the rest of the sprawling state—75 districts—goes without even secondary care. According to the NRHM’s fourth common review mission report, of the 515 community health centres in Uttar Pradesh, 308 were below norms laid down in the Indian Public Health Standards.
The ailments of the poor often have nothing to do with the agendas of rich and powerful pharma companies. Are there lessons India can learn from the world? Experts say that the US has one of the worst public healthcare systems in the developed world. But in most countries, in Latin America or Europe, universal healthcare been achieved through governments. In Asia, Sri Lanka and Thailand can teach India some lessons on the health front. So India may be a powerful nation simply by dint of its size and market. But it is also a ‘sick’ nation, where there’s no help for the poor when they fall sick. It’s a country where a poor man can die on the pavement outside a gleaming state-of-the-art hospital with the best medical technology in the world.
By Amba Batra Bakshi & Lola Nayar with Sharat Pradhan, Madhavi Tata, Dola Mitra, Panini Anand, Chandrani Banerjee, Prarthna Gahilote and Prachi Pinglay-Plumber
Apropos The Doctor Only Knows Economics (Feb 18), I have witnessed the gradual erosion of government involvement in the healthcare system, caving in to private players who very rarely are concerned with the plight of the less privileged. A case in point is the Seven Hills Hospital in Mumbai, built on a ppp with the BMC and leased to the Seven Hills Group on the understanding that 20 per cent of its beds would be for the poor. As expected, nothing of the sort is happening. But what is worse is the Congress-NCP patronising the place to implement the state employees health scheme where the hospice gets reimbursed. The scheme itself is flawed because it is operation/procedure driven which means that a lot many patients are subject to unnecessary surgeries because only then does the hospital make money.
Dr Thomas Kuruvilla, Mumbai
The private hospitals in metros are nothing but medical malls. That said, with state hospitals in the state they’re in, what choice do we have?
Anil Sood, Delhi
The state shouldn't be in the healthcare business for it never pans out. Certainly not in a country like India. Studies show that even districts which have more than one government hospital show no better health outcomes than districts which have none.
Are we really better-off in the liberalised era, post-1991, compared to the Indian state of yesteryear with its socialist mindset? At least then the aam aadmi was better off mentally—he knew that the government of the day worked for him and his interests even with the meagre means at its disposal.
H.C. Pandey, Delhi
This is the reality of India. There are lots of welfare schemes, the state puts lots of money in them, but it unfortunately goes into the pockets of those who hold power. India will shine only when everyone is able to ‘buy’ whatever they need.
Thank you to all those who have taken the trouble to read the article and share their thoughts. Out of the arguments made here, there are two that perhaps need answering. So here they go.
1. The first part of the article compares outcomes (relative percentages of population of the religions concerned) irrespective of the process that led to those outcomes - whether immigration, relatively faster population growth or conversions. This was for two reasons. One, to put the figure of 2.3 per cent in "numerical perspective", as the article itself explained. The second reason was that outcomes are ultimately what the crux of debate is about. The rest of the article in any case dealt with process - or conversions in this case, from both a contemporary and historical perspective.
2. Some commenters have tried to cast doubts on the reliability of Census 2001. Those who do this should bear in mind that Census 2001 was conducted by a BJP government. Considering the extreme importance that BJP gives to this issue, it would be reasonable to expect that IF it had perceived a problem with the methodology that was distorting the numbers, it would have fixed it. As the article mentioned, BJP or BJP-supported governments have been in power for 10 of the last 40 years, or about a quarter of the time, and the only reasonable conclusion one can arrive at is that any misreporting of numbers, real or perceived, would be marginal and hence, not of importance.
To all other arguments made, my answer is the following: Please read the article again, with particular focus on the quotations of Vivekananda and Monier Williams, and the history of the missionary efforts in Bengal and their outcome.
You are very right. Outlook will never publish a story on how corrupt netas have cornered the higher education system and its consequences. They will publish another 25 page article by Arundhati Roy explaining why India is a fascist country and markets and economic growth are evil. Outlook is not concerned with the problems of the people - they have other, more lofty aims. It would be nice if they made a beginning by hiring a few journalists who have a rational, evidence based outlook and who are not eger to prove their "progressive" credentials by aligning with outmoded (and outvoted!) socialist ideas.
Your idea is very welcome but it will never be implemented because, medical education is a big business run by politicians in power by proxy. When was last time a media house like Outlook did a edition on this mafia, political mafia that runs education as business?
Outlook which runs pages and pages to weep about Kasab and Afzal Guru has no time for these petty folks !!
Healthcare can be made geuninely public friendly only when medical education is made a government reponsibility.
District hospitals need to be transformed as educational institutions, so that more genuinely intelligent and committed people turn into doctors - as happens all over the world.
The shameful fact is that despite having some of the best healthcare facilities (I'm not talking capacity) in the world, more than 95% of Indians do not have access to them because they cannot afford it. Even the middle class (supposedly affluent) have to sell home and hearth to get their loved ones treated at these facilities. Can the government not do something about it? Will the poor forever dream of good treatment for their afflicted ones?
Mitra >> I have nothing against the government providing health care, but has it worked in India? The answer is No. Studies show that districts with more than one government hospital show no better health outcomes than districts without any government hospital.
I agree with you mostly. Instead of building a hundred Government Hospitals, the government should build a hundred thousand water tanks giving potable water in remote villages and also help to build a million toilets/septic tanks. Sanitation investment what we need. But our socialist czars are interested in replicating more and more AIIMS. Why? The Moneyed feudal elites who preach socialism find it more easy to profit from AIIMS like facilities since they can be hacked to help the rich find subsidised surgical treatment. But building septic tanks and taps in remote villages does not help these rich feudal elite for obvious reasons.
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