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HindustanTimes Thu,02 Oct 2014

Columns Samar Halarnkar

Saving Kiran Ravi
Samar Halarnkar
July 17, 2013
First Published: 13:50 IST(17/7/2013)
Last Updated: 01:16 IST(18/7/2013)
India has 19 doctors and nursing staff per 10,000 population, considerably less in states such as Bihar, UP, Rajasthan and Jharkhand.

When Kiran Ravi, 14, started bleeding from his nose and mouth, doctors at Bangalore’s government-run Indira Gandhi Institute for Child Health, were baffled. After two months, they told his parents, Stephen and Mary, there was little they could do. Take him, the doctors said, to the Christian Medical College (CMC), Vellore, in neighbouring Tamil Nadu.

At CMC, one of India’s leading hospitals, Kiran’s condition was diagnosed: very severe aplastic anaemia, a deadly cancer. Kiran’s best option is a Rs. 10-lakh bone-marrow replacement. But that needs a donor with matching marrow and money that Stephen, an unemployed electrician, and Mary, a maid, do not have. Testing for a match alone would cost Rs. 80,000. CMC says it will contribute Rs. 4 lakh.

This changes nothing. Kiran’s illness has already cost Stephen and Mary Rs. 1 lakh, and moneylenders, who lent them money at 20% interest, hound them daily. The couple’s annual income is less than Rs. 80,000, or about 800% higher than India’s urban poverty line. So, State help is unlikely. The only hope is that some kind person will help Kiran, who, as you read this, is dying, his bone-marrow failing to produce the cells his body needs to stay alive.

Like Stephen and Mary, some 250 million Indians — unknown and unrecorded — risk slipping into poverty if they face just one health crisis, a report by the Independent Commission on Development and Health said in 2010.

These days, Narendra Modi, the man in a tearing — almost desperate hurry — to lead India, will convince you that the nation’s concerns revolve around his brand of nationalism and development through the private free market.

The Congress, the party desperate to hang on to power despite a record of inept governance, secularism of convenience and corruption scandals, will convince you that India must stop Modi and accept its shoddily designed welfare programmes.

Our concerns, as a slew of recent academic research warns us, urgently need to focus on one of two subjects (the other is education) that holds the key to the future but is instead ignored: Public healthcare. Here’s how bad it is.

The average visit to a healthcare provider in a public clinic in Madhya Pradesh lasted 3.6 minutes, and only 12% of the diagnoses were correct, with no differences between trained and untrained personnel, reveals a 2012 study by a group of five researchers from the World Bank and three US and Canadian universities.

“Incorrect treatments were widely prescribed,” said the study, published in Health Affairs, an international journal, and brought to public attention last week by Lant Pritchett, Harvard professor and occasional counsellor to Rahul Gandhi. A later, unpublished study finds the same healthcare providers performed dramatically better in their private practices, said Pritchett.

Physical wellbeing is critical to emerging India. Shabby health services in large part ensure the country has more malnourished children and adults and sick people than anywhere else in the world. Ill-health is responsible for slow-learning, job losses and low productivity on farms and in factories.

Any country that has less than 23 doctors and nursing staff per 10,000 population faces a crisis, according to the Global Atlas of Health Workforce, produced by the World Health Organization. India has 19, considerably less in states such as Bihar, Uttar Pradesh, Rajasthan and Jharkhand. More than half the medical workforce does not practise in the formal health system, public or private.

The problem is acute in rural areas, where the majority of Indians live. For instance, a May 2013 study by the Public Health Foundation of India found that primary health centres in Chhattisgarh were almost exclusively staffed by medical assistants, paramedics and ayurvedic doctors. In Madhya Pradesh, only 11% of healthcare providers had a medical degree; in Delhi, that figure went up to just 52%, the Health Affairs study said.

The private sector provided more than 70% of the hospital beds added over the last decade, says a McKinsey study. In Madhya Pradesh, only 8% of patients use public healthcare. It’s not surprising that hospitalisation costs roughly doubled over the decade ending 2005, government data reveals.

India’s health budget for the current financial year is a Rs. 37,330 crore, or 0.32% of gross domestic product (GDP), and is growing slower than GDP. On almost every health indicator — from infant mortality to out-of-pocket spending by poor patients — India trails its South Asian neighbours and many of the world’s other low-income countries.

Is there anything uplifting about this gloom? Only if you twist some facts. On three counts, insurance coverage, doctor density and share of private hospital beds, India’s 2010 figures match or better those of Brazil, Thailand and South Korea — if you consider 1965 data from those countries.

To be sure, there has been progress, but it is slow. In a country where one in eight medical payments are made by patients themselves — one of the highest rates in the world — an innovative national health insurance scheme allows 35 million people to use specific public and private facilities free. The target: 300 million.

Universal healthcare would cost just over Rs. 1,700 per person per year, delivered through private and public institutions, says a 2012 study by researchers from Chandigarh and Toronto, published in the journal Plos One. The government would need to set aside 3.8% of GDP, easily achievable, if India so chooses.

“Why is the messy reality of (Indian) healthcare so hard to acknowledge and confront?” asked Amanda Glassman, director of the Center for Global Development, a think tank, in a blog.

Perhaps, because Modi, the Congress, the media — and, let’s admit it, all of us — find all this rather boring. The fate of Kiran, the school boy with the dying bone marrow, appears to have little to do with the concerns of people like you and I.

Samar Halarnkar is a Bangalore-based journalist

The views expressed by the author are personal


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