Health, for a price

The government makes claims about setting up superspeciality hospitals when the need of the hour is the upgradation of basic health care facilities.

in New Delhi

MANY of Delhi's resettlement colonies emerged in the mid-1970s when Sanjay Gandhi relocated a large number of the city's poor. Several plots in these areas were given in exchange for vasectomies that were done as a part of the government's family planning programme at that time.

Some of the plots were sold to people who could afford to consolidate them, and in the course of time resettlement colonies emerged. The people who stay in these colonies range from those belonging to the middle class to some of the poorest sections of society.

There are two government hospitals in the resettlement colony near the Uttar Pradesh border, the Swami Dayanand Hospital and the Guru Tegh Bahadur Hospital. There is a local dispensary, and a number of private clinics dot the streets. But do the residents of the area have access to basic health facilities? Says Chaya, a resident: "Many people visit government hospitals. Private hospitals are expensive. [In government hospitals] one has to wait in long queues for every small thing. When I was sick and could barely stand I was asked to run from one part of the hospital to the other."

A member's illness places an enormous financial burden on the family. Says Dulariya Devi: "My husband had symptoms of tuberculosis. Under DOTS [the internationally recommended TB control strategy], the government programme, we have to go and collect medicines from the dispensary. We have four kids and when he fell sick he could not work and it was difficult to manage at home. Four months ago we went to a private hospital. It cost us more than Rs.20,000 and he was not treated properly. So we took him back to the Guru Tegh Bahadur Hospital. The medicines were free. Most of the cost incurred was in travel and in staying there instead of working."

Most poor people go to private nursing homes because in government hospitals they have to wait in long queues and go through the rigmarole of procedures, resulting in the loss of working days and therefore earnings. Says Chaya: "My husband rides a cyclerickshaw. He earns Rs.3,000 a month. In August 2003, suddenly his hand began giving trouble. It began to shake. We took him to the Guru Tegh Bahadur Hospital. They gave him injections and a few capsules. They did not even check his blood pressure. Later on we took him to a private practitioner who asked for three X-rays to be taken in a diagnostic centre. At the Red Cross private clinic I had to pay more than Rs.90 per injection. I could not afford it after one week. Some time later my husband complained of a pain in his head. We took him to the Swami Dayanand Hospital. They asked me to go to the Emergency for a CTA scan. This cost us another Rs.940. We had very little with which we could pay this kind of money. They charged us Rs.50 for food and all the medicines had to be bought from outside. When he stopped working my child had to start working, even the smallest medicine cost money."

Though private nursing homes and hospitals are very expensive, the residents of this area do not have to face the inconveniences they do at a government hospital. They usually visit the local dispensary for less serious illnesses but go to the government hospital when they think that the situation is serious. Says Chaya: "If one person is in hospital everyone else in the family has to run around. People go to private hospitals because for the very poor, time is important. They want to get out of the hospital fast. The government dispensary opens at 10 a.m. and shuts at 1p.m. It has over 300 patients waiting to see the doctor. One has to run around for all the slips of papers and documents. After all the waiting we are asked to buy medicines from outside. The private doctor may prescribe 10 different medicines but at least their timings are right."

At the government dispensary long queues of patients can be seen. The doctor on duty, Dr. Deepti Sachan, says, "We could see up to 350 patients a day. We are open from 9 a.m. to 4.30 p.m., with a half-an-hour break for lunch." The cursory glances that she manages to give the prescriptions of patients hardly seem to merit such a long wait. But for the residents of this area, it is an important facility. Some of them have tried changing the state of affairs in the dispensary but to no avail. Says K.N.P. Nair: "In the five years no one from the government has come to have a look at the place. There is no adequate facility for water or medicines - there is an open drain that borders the building. The doctors do not come on time. I complained to the PWD [Public Works Department] office but no action has been taken."

Whatever problems the existing government hospitals might have, people here believe that the answer does not lie in more private hospitals, but in improving the conditions in the government hospitals. Says Kunti Bhai, a resident of the poorer `jhuggi' area of the colony: "My 10-year-old child fell sick. I put him in the private hospital for a few days. When the fever did not abate, they charged me Rs.1,000 without even telling me what was wrong. The doctor performed an operation. After 10-12 days, the doctor said another operation had to be done. Finally the boy was treated at the Guru Tegh Bahadur Hospital. I should have gone there in the beginning."

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SIX new institutions along the line of the All India Institutes of Medical Sciences (AIIMS) are to be set up in the country, in Bihar, Chhattisgarh, Madhya Pradesh, Orissa, Rajasthan and Uttaranchal. One medical college each is to be established in Andhra Pradesh, Jharkhand, Jammu and Kashmir, Tamil Nadu, Uttar Pradesh and West Bengal. In its Interim Budget, the Finance Ministry has projected a total plan outlay of Rs.1,779 crores for the health sector, an increase of more than Rs.300 crores from last year. A major portion of the money will be spent on setting up AIIMS-like institutions under the Pradhanmantri Swasthya Suraksha Yojana, which is touted as a major step in the "India Shining" campaign.

But are new superspeciality hospitals and medical colleges really needed? "No," says Dr. Puneet Bedi, a consulting gynaecologist based in Delhi. "Much before the government plans an AIIMS for every State in the country, it should evaluate if the AIIMS has done anything to improve public health in the country," he says. In 1946, the Health Survey and Development Committee chaired by Dr. Joseph Bhore, an Indian civil servant, recommended the establishment of a national medical centre, which would help nurture a core of highly qualified manpower to meet the nation's health care needs. The AIIMS was set up largely as a result of the efforts of Prime Minister Jawaharlal Nehru and his Health Minister Rajkumari Amrit Kaur, with the help of a grant from the government of New Zealand under the Colombo plan. It was created in 1956 as an autonomous institution.

What a hospital like the AIIMS can do at best is to set a high standard for health care. However, what is needed at the moment is drastic action to improve primary health care in the country. According to Amit Sen Gupta, co-convener, Jan Swasth Abhiyan, which consists of a number of national networks that work in the area of health, India has one of the poorest records in health care expenditure by the government both in terms of real expenditure and in terms of percentage of the total health care costs. The situation has become worse as prescriptions for restructuring the health sector over the past decade have been designed to maximise outputs from greatly reduced government support. The burden of cutbacks has fallen on supplies and materials, resulting in the virtual destruction of the public health infrastructure. The same government now says that the public health system has to be replaced by private services.

There is a fundamental contradiction in the concept of private medical care. Says Sen Gupta: "A private medical care provider stands to profit from illhealth. The larger the number of people who fall ill and the longer they remain ill, the larger the profit for the care provider." The private health sector grew unabated in the 1950s and 1960s and with it emerged the phenomenon of `medical entrepreneurship', its backbone being private health clinics and nursing homes. In the 1990s, the organised corporate sector began to enter the area of medical care.

The practice of medicine became technologically intensive and corporate entities, which could invest in expensive state-of-the-art technologies, began to control the medical care industry. Says Dr Bedi: "In this yeomanship of medical entrepreneurship and haste to buy the latest gadgets, public health was completely neglected. What happened was that ultrasound tests and CTA scans and cardiac, bypass and prosthetic joint surgeries were introduced without looking at costs and benefits. For instance, though ultrasound was introduced in the 1980s as a revolution, there is no proof that it has improved neo-natal care, and its misuse has resulted in large numbers of female foeticide."

According to Dr. C. Sathyamala, an epidemiologist who is part of the health and women's movement in the country, a dual system for the poor and the rich is being proposed to tackle the issue of equity in health care without altering the process of disinvestment that is under way. A high-technology-based medical service that is on a par with the system that is available internationally is to be provided by the private sector for a small section of the elite that can afford it and to cater to the needs of overseas clients in order to earn foreign exchange. "For the poor, all the government will be obliged to provide free is a minimum clinical package along the lines suggested in the World Bank Report of 1993, which bears little relationship to the morbidity profile of the poor and is inadequate to meet the health needs of this population," says Dr. Sathyamala.

The need of the hour is for the government to be more involved in providing health care. Says Sen Gupta: "No country has succeeded in providing universal access to health care without pledging a major share of public resources to the health sector. We need to have a closer look at the whole philosophy of healthcare in the country."

Facts speak

* The percentage of Gross Domestic Product (GDP) allocated for health dropped from 1.4 per cent in 1991-92 to 0.9 per cent in 2001-02.

* India is one of the three countries where maternal mortality rates continue to be on the rise.

* The National Health Policy of 2002 does not mention the goal of providing universal access to health, a departure from the National Health Policy of 1983 and contrary to the goals of the Alma Ata Declaration.

* Although female foeticide has been on the rise over the past six years, and despite a Supreme Court directive to the government to enforce the Pre-Natal Diagnostic Techniques (PNDT) Act, not a single doctor has been prosecuted as yet.

* Public expenditure forms only 14.3 per cent of the aggregate expenditure on health, one of the lowest figures in the world.

* The annual per capita expenditure on health is just Rs.160

* The infant mortality rate remains at a high 70 per 1,000 births; in the case of the Scheduled Castes and the Scheduled Tribes, the figures are even higher at 83 and 84.22 respectively.