Kollengode S Venkataraman (written in 2004)
The life span of Indians has impressively increased from 49 years in 1970 to 65 years in 1998. And the infant mortality rates have dropped from 146 per 1000 live births in the 1950s to 70 per 1000 live births in 1999, still relatively very high.
But these observations belie the harsh reality of India’s reckless, exploitative, greedy, and irresponsible healthcare industry that holds in its vice-like grip a large number of people (over 70% of the population, or 700 million) who have very little disposable resources. Of these, many (rural and urban poor) have no disposable resources at all.
While the healthcare industry shortchanges India’s citizens in all possible ways as you will see in this article, it
provides quality healthcare including organ transplants and open-heart surgery to people from the Middle East, Central Asia, and other South Asian countries. This is the medical equivalent of “outsourcing” in the IT industry. Going to Europe or North America for medical treatment will cost these people several times more than it does in India. Now Europeans too go to India for medical treatment.
This gives good publicity in the global marketplace apart from earning foreign exchange. So, India’s elected officials and its babudom close their eyes to what this is doing to further balkanize India.
In this background, on Sunday, November 2, AID (Association of India’s Development), an organization mostly of graduate students from India, held a lecture at CMU by Dr. Abhay Shukla on the deplorable condition of the Indian healthcare industry. Shukla is an alumnus of All-India Institute of Medical Sciences, New Delhi, a physician-activist working in rural Maharashtra, a recipient of the prestigious Ashoka Award, and a founder of Jan Arogya Abhiyan. AID supports Shukla’s work in India. There were 15 people in the audience, mostly students. Shukla put the Indian healthcare industry in context:
* In any society, public health is the government’s responsibility, whose major thrust is increasing health awareness among people, prevention of diseases, immunization, pre- and neo-natal care, etc. In India, governments are spending less and less proportion of their GDP on public health. The health of people (mostly poor) has suffered, and society as a whole pays the price.
* Most of the taxpayer money spent on public health goes to paying salaries of healthcare workers, with very little spent on infrastructure, equipment, or modern diagnostic tools. Government hospitals lag behind even more in an industry where new developments are sweeping across the landscape at breathtaking speeds.
* Health insurance covers only 7% of Indians, mostly urban and affluent. A vast number of people don’t even know what health insurance is.
* India spends 6% of its GDP on healthcare, with only 1% coming from governments. The remaining 5% is what people spend mostly out-of-pocket for private hospitals and private doctors.
* Healthcare provided by private doctors and hospitals now accounts for over 80% of India’s healthcare industry, which is mostly urban, unregulated, with no mechanisms to check its practices.
* The Indian Medical Association, the professional body of physicians and surgeons, is incapable of regulating itself (much like it is in the US).
* Naturally, healthcare costs are the single most common cause for people’s indebtedness. People either sell their properties or take loans way beyond their capacity to repay.
* People from established sections (politicians, bureaucrats, and the organized sector have first dip into the public healthcare system in government-run teaching hospitals. Only the leftovers go to the poor.
* There is rampant abuse of modern medicine by many of India’s doctors, particularly in treating poor and illiterate patients. Use of entirely avoidable injections and saline infusions is most common among doctors since they charge more for these services than for tablets and drinking fluids. The abuse of antibiotics and corticosteroids is also widespread, giving rise to resistance to antibiotics in patients, which also has an epidemiological consequence.
In addition to what Dr. Shukla presented in his address to the AID group, also consider these:
* The gender ratio among under 5-year-old children in India is scandalous. Even among the educated and upwardly mobile people in Gujarat, Punjab, Haryana, and other places, we have only around 800 girls for every 1000 boys. Education has not helped in counteracting deeply held cultural biases against daughters. The Indian middle class has no guilt in using modern technology (amniocentesis, ultrasounds, etc.), and India’s radiologists and OB-GYN doctors have no scruples or conscience in making India’s pregnant women abort female fetuses.
The social consequences of this are not hard to fathom.
* The Indian private healthcare industry is heavily biased towards curing diseases rather than preventing diseases because curing is where all the money is. There is little incentive for private doctors, hospitals and pharmaceutical companies to stress preventive care.
* India has the highest number of people with HIV, a staggering number of over 4 million people. HIV is no longer confined to drug users and sex workers (prostitutes). HIV is now very much a mainstream problem in some states.
* The incidence of leprosy and TB diseases is the highest in India.
* Taking legal recourse to medical negligence by doctors and hospitals is like jumping from the frying pan into the fire because the Indian criminal justice system is even more corrupt. In their infinite wisdom, Indians pray that they complete their journey on this earth without ever having to visit a lawyer. But this may be changing as described by Aditi Iyer further down.
* The most diabolical aspect of the Indian healthcare industry is the kickbacks physicians receive from diagnostic labs. Physicians prescribing lab work (blood and urine analysis), X-rays, CAT scans, ultrasounds, echocardiograms, EKG, etc. get as commissions nearly 30% of what the labs charge the patients. This is in addition to what these physicians charge patients directly for their services. So, there is great financial incentive for physicians to order questionable, expensive tests more often than necessary, further exacerbating patients’ financial burden. Remember, most of the expenses are out-of-pocket for the patients.
So, it should surprise no one that a recent World Bank study reported “[The Indian] public remains badly informed about much of the health system. It knows very little about whether the health services [they receive] are appropriate, who is benefiting from them, whether the quality is sufficient, or whether people are getting good value from public and private spending on health…… There are major problems with equity, vulnerability, financial catastrophe, quality and accountability in both public and private health sectors.
The problem is receiving social scientists’ attention. Aditi Iyer (Health for the Millions, Vol. 22, No. 4, July-August, 1996) writes that the Godlike image of doctors in India is finally changing:
… An overwhelming majority of doctors are employed in an individual capacity in the profit-oriented private sector, in which the sick does not receive medical care without making on-the-spot payment. So central are monetary transactions to the healing, and so repeated is the experience of it, that in the public eye, doctors have begun to resemble traders……
“Accompanying this altered image are reports of medical negligence, malpractice and unethical practices that have increasingly made their way into the mainstream media. With aggrieved patients and/or their crusading relatives taking doctors through the orchestrations of civil and criminal lawsuits, the unquestioned trust that once underpinned the doctor-patient relationship has all but disappeared.”
is no wonder counter-movements are coming up all over India, led by social activists who are often physicians themselves, such as Dr.
Abhay Shukla. They work to educate rural people on the basic health care issues, on preventive care, social hygiene, and how to care for minor ailments themselves, and when and how to seek medical help so that the healthcare system exploits them less. They also try to make the Indian physicians in rural areas accountable to their patients.
Dr. Abhay Shukla works in rural Maharashtra in Kolahpur District. The most impressive part of Dr. Shukla’s work is developing pictorial educational material with minimum verbiage on healthcare issues that are very effective in teaching rural people, given the high levels of illiteracy. These materials can be easily used all over India.
Another feature of Shukla’s work is making patients shame exploitative doctors. People have taken silent and peaceful protest processions in rural towns to bring their grievances against doctors to public notice, and put the doctors on notice to change their professional behavior. This has increased the overall awareness of the underlying issues.
Obviously, India needs more Abhay Shuklas in its healthcare system. You can contact Dr. Shukla at: abhayseema@vsnl.com
The website of the organization is: www.cehat.org
Editor’s end note: The challenges and significance of Dr. Shukla’s work are enormous since people like him are trying to change the basic premises of India’s healthcare system. And in the Pittsburgh metro area live a fairly large number of accomplished healthcare professionals of Indian origin, and we also have other resourceful Indian organizations. So, AID should have tried to get a wider audience for Shukla’s talk. People like Shukla need all kinds of resources in addition to money. A wider exposure for his yeomen work would have increased the odds for Shukla to have access to these other resources as well.