On a trip to Bihar this week, I came across a story in the local edition of a national newspaper reporting a study by the Bihar chapter of the People’s Health Movement. The story reported the costs incurred by a sample of patients who had been admitted to government-run health centres.
They found that the average cost per admission was about seven times the average monthly income of the respondents, which led to high levels of distress sales and borrowing from money-lenders. It was astonishing how these costs were incurred in government facilities, where many believe that care is largely free. Of course, it would come as no surprise to learn that the recent National Sample Survey data reported that the out-of-pocket expenditure has gone up four-fold in the private sector.
On the same day, an email update from an e-newspaper reported that the Medical Council of India was silent on allegations that ‘ghost’ doctors were being roped in to pretend they were faculty to secure recognition of medical colleges, with the collusion of the inspectors.
These stories followed yet another typical week of health scandals, from yet more people blinded by poor quality of care in a cataract camp to health ‘camps’ being fronts for companies to market pharmaceuticals and other medical products.
It seemed as if the huge effort that my colleagues and I had invested over the past year in synthesising academic evidence to document the state of India’s healthcare system, published last week in the Lancet, was unnecessary.
The state of the healthcare system was reported daily in our media and the answer was clear. Put simply, India’s healthcare system is one of the greatest stains on the conscience of our modern State, for it is one of the most regressive in the world. At one end of the healthcare spectrum, people get pampered in hospitals, which could comfortably double-up as luxury hotels, receiving unnecessary interventions aimed primarily at recouping the investments of their promoters, while at the other end, people who desperately need medicines or surgeries are denied their basic right to life.
Across this spectrum, the enormous asymmetry of power and information, and the complete absence of regulation by either the State or the medical profession means that healthcare in India today works like a lottery: You are just plain lucky if you find that gem of a facility or practitioner who will care for you with dignity, transparency, evidence and ethics.
Indeed, this sorry situation is a major reason why the country, according to latest UN report released earlier this week, ranks behind 129 other nations on human development. Incredibly, the list of countries ahead of India also includes Iraq, which despite a decade-long conflict enjoys a higher life expectancy than India.
Of course, none of this will be news to many ordinary citizens who could have written the conclusions of the Lancet paper just by reading the newspapers or being exposed to the iniquities of our healthcare system through their personal experiences. The real mystery is: Why do most of us not get upset by this injustice?
Two recent books by eminent commentators on India’s deprivations voice the same anguish. Amartya Sen in this new book of essays, The Country of First Boys, writes that it is this “overarching division between the privileged and the rest” and “the silence with which it is tolerated, not to mention the smugness with which it is sometimes dismissed”, which should keep us awake at night.
Perhaps most tragically, according to Sen, “these deprivations are not hard to overcome, even within the means that India now has”. After all, India is the world’s factory of cheap medicines and highly-skilled doctors. In a recent book, Looking Away: Inequality, Prejudice and Indifference in New India, suggests that the privileged have chosen to deal with this injustice by simply “looking away”. More repugnant is the possibility that we simply do not care.
The Lancet paper concludes that we need to look beyond the usual prescription of more resources to fix the system. It is clear we need something quite radical, something which unifies our country around the need for a root and branch reform of our healthcare system for, regardless of our social class, we are all being short-changed.
Nothing short of a completely fresh vision for India’s healthcare system — with strong leadership by the government and full participation of the health professional communities and civil society — can heal such a fundamentally flawed system.
Our successive governments, which have parroted the mantras of economic development and social justice, should note the mountain of evidence indicating that such goals are unattainable without attending to this malady.
The answer on how to go about this is also patently clear from countries around the world, which have fixed their healthcare systems in recent decades: Universal health coverage, a national healthcare system which integrates both the public and private sectors, operating with a common set of standards and regulations, where all citizens are guaranteed accountable and quality care which is free at the point of delivery is one practical concept among many others.
It is no accident that those countries which are at the top of the human development league are also those which enjoy universal health coverage. Until India commits to this goal, there is no chance of it ever joining those countries or enabling its people to fulfil their rightful destinies and that of our country.
(Vikram Patel works with the Public Health Foundation of India and the London School of Hygiene and Tropical Medicine. The views expressed are personal)