India’s Dismantled Healthcare

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Public sector health care in India is negligent and poorly administered. Did this create India's monstrous private health care?

On Sunday, March 26, 12 children were taken ill after being administered ‘antibiotics’ at the state-run Gandhi Hospital in Secunderabad. Now, investigators aren’t sure what the children were even given – what was supposed to be Amoxiclav could have instead been phials of expired Sodium Sulphate.

The hospital has been in the headlines – twice in a short span of two months. Just two weeks before, a patient was forced to borrow his son’s toy tricycle to transport himself between floors – as he couldn’t afford the bribe money the ward boys were charging for a wheelchair. Suffering burn injuries from electrocution in August, his wife has been bringing the tricycle to each of his follow-up visits.

The hospital is one of the largest government hospitals in the city, catering to more than 2000 inpatients every day with only 1,100 beds. The situation, like in many hospitals, is bad enough that patients often sleep on the pavement – waiting for their turn.

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In Orissa, last year an impoverished man had to carry his wife’s dead body on his shoulders and walk for over 12 kilometres after the hospital failed to provide an ambulance to take the body back to his village.

Public healthcare in India is appalling, to say the least. Poorly administered, negligent patient care – often muddled in bureaucracy, red tape, and corruption – is the norm. It caters mainly to the poor – but even they are beginning to think twice because of the risk of mistreatment.

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(Image: 7MB) Baig came from Mysore to get treatment for his paralysis, but forgot to bring his Aadhar card. He sleeps on the pavement until he can prove his identity.

India’s private health care is profit oriented, expensive and often times exploitative. Reports abound of medical doctors willing to amputate children’s limbs for a fee to facilitate them begging or of indulging in illegal organ trade. India’s fabled Aam-Aadmi – the common man – has no access to decent medical care.

The findings of the 71st round of the National Sample Survey confirm that faith in public health has declined over the years – more than 70 percent of ailments in India were treated by the private sector, with patients spending up to eight times more than they would have in a government hospital. According to a Lancet study, over 39 million enter into poverty every year from their private medical expenses.

So why do India’s sick overwhelmingly turn to the private sector?

Over-Prescription, Incompetent State Clinics, Unscrupulous Private Practice

In the 1980s, India claimed to have set up a ‘national health infrastructure’. But the absence of reporting on diarrheal diseases by the government’s primary health centres prompted the United Nations Children’s Fund to investigate.

What they found was that rural healthcare was overwhelmingly taken care of by Rural Private Practitioners (RPP). In a book titled Rural Private Practitioners, Jon E. Rohde and Hema Viswanathan surveyed over 800 RPPs – and found that 48 percent had no medical training at all.

In Hazaribagh, Jharkhand, a fake doctor, killed three people to death in his “nursing home”. This is not an isolated incident. It is endemic – there are many who pretend to be medical doctors without any qualifications. Most of them prescribed medicines that alleviated symptoms rather than the condition’s cause and gained a reputation for producing results.

Government hospitals, by contrast, are bureaucratic, involve bribes (petty and substantial) and make patients run around. As far as rural India was concerned, ‘the doctor’ was a private one.

In the cities, it’s a different tale. The “five-star” private hospital is heavily advertised – making healthcare an experience instead of a necessity. “Health Tourism” is a profitable venture which is heavily advertised sector, inviting people from across the world to pay for health care. And as a 2015 report published in the British Medical Journal detailed – the scope for malpractice is limitless.

According to the report by Dr. Arun Gadre, doctors get kickbacks up to Rs. 40,000 for referrals to angioplasty specialists. Continuing the trend seen in Rohde and Vishwanathan’s work, it is often that doctors trained in homeopathy or Ayurveda end up prescribing allopathic medicines. Over-prescription of medicines and tests is another common practice to get kickbacks from drug companies.

And doctors aren’t flocking to the hinterlands either. Fewer than 20 percent of Indian doctors work in rural areas. This is largely the outcome of the medical education system – which encourages tertiary care over the primary. 50,000 students get into MBBS programmes in India each year, and the mo five-year-degree is an expensive investment. For many new doctors, a stint in a village just won’t pay the bills.

Private healthcare in India is a profitable business with few checks and balances. And only those with stuffed wallets are welcome – India’s out-of-pocket health expenditure as a percentage of private health expenditure is 89.1 percent. It’s a country where only 18 percent are covered by some form of insurance – so medical bills are often a sudden, unplanned expense.

Is there hope for public healthcare?

The Reluctant State

In Hazaribagh Sadar hospital, patients couldn’t get their Rs. 10 blood tests taken because the institute had run out of the two chemicals it required. With no options, they turned to a private clinic – charging Rs. 300.

The idea that private health can fill in the gap of state health has been in play since independence.

Speaking to The Hindu Business Line, Professor Imrana Qadar calls the state “a protector of the medico-industrial complex in this country”. In 2014, she edited the Social Development Report: Challenges of Public Health, where the question and evolution of public health in India is analyzed. It reveals a trend of steady de-emphasis on the role of the state in healthcare. The problem is that the necessary infrastructure for preventative healthcare is lacking – and the technology-driven private sector only presents expensive cures for growing problem.

As economist Kenneth Arrow wrote in 1953, “It is the general social consensus, clearly, that the laissez-faire solution for medicine is intolerable.”

Is the state willing to bounce back into healthcare?

The Future

The proposed National Health Policy aims to take spending on health to 2.5 percent of GDP by 2025 (currently it stands at 1.16 percent). This would equal India’s estimated defence spending in 2017, and take India out of a club of low spenders on health.

While some doctors are understandably averse to increasing bureaucracy, there are calls for the Indian Medical Service (IMS) to be restarted. With a legacy dating back to the East India Company, the IMS served military (and later civilian) medical requirements. The idea of restructuring it into a cadre akin to the Indian Administrative Services and creating an all-India deployment of skill and decision making has been pitched by government officials.

An efficient IMS could improve rural health coverage, and bring a respectable state back into healthcare. If current trends continue, health care will remain a luxury for a privileged few – and a curse for the millions of poor.

The dismantling of public healthcare through inefficiency has been an inadvertent bonus for the private healthcare industry. It’s time the state stepped up to the plate and delivered on keeping its citizens healthy.

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