Ratna Devi and her nine year old daughter Seema (names changed) came to AIIMS, New Delhi with a large tumor over Seema’s knee. The tumor was not a new discovery and had been thriving on the little girl like a blood sucking leech for the last one year. An enquiry revealed that the family was from Rajasthan, around four hundred kilometres from Delhi, the father was a farmer who owned a small piece of land barely enough to sustain his wife and Seema’s three other siblings, all younger than her. The initial treatment of the tumor was done in a private set up in Jaipur. The concerned hospital dragged on her treatment, financially bleeding the family white. Upon revelation that the tumor was pretty much non operable; she was sent to AIIMS with a small piece of paper which curtly mentioned,referred to a higher center! Her referral to a tertiary care centre was more like passing the parcel in a game of fun! There was a small catch in this otherwise straightforward tragedy. The initial treatment of the tumor caused the family a sum of twenty thousand rupees (approx USD 300) which was borrowed from the village money lender at an exorbitant interest rate and this now threatened the family’s only means of sustenance, their small piece of land. Subsequent treatment in Delhi necessitated that the land be sold off. Seema underwent an amputation of her limb with us; she was advised chemotherapy which was taken partially as the family was not able to sustain living in Delhi any longer. In the absence of chemotherapy, I am sure Seema would not have made it beyond one season. The hospital records showed that Seema was lost to follow-up, for me, Seema was murdered.
Seema’s story is not a one-off in this country. An article published in Lancet on June 26, 2016 (from the Faculty of Social Sciences, Open University, Milton Keynes, UK and co-authored by Public Health Foundation of India) reveals the tragedy of India’s multi faceted, near defunct medical healthcare in more objective terms. The article evaluates the role of private players in the country’s seriously unwell health care system. It classifies countries into five types of private sectors available in providing health care to its people. Unfortunately India has been bracketed with Nigeria in the group of nations with “Dominant Private Sector”. How astounding could that be? At the time of our ‘tryst with destiny’, we were made to believe that we are committing ourselves to socialist principles of governance. Then what went wrong that we have landed into a group where predominant system of healthcare is private? Or was it that healthcare was purposefully left ‘unattended’ for the private enterprise to run amok? Or may be, healthcare as a vital investment was beyond imagination of the past and present rulers of the country?
It is more painful when the same article lists Sri Lanka (with Thailand) in a group where “private sector compliments the universalist public sector”. The private share in India mounts to an astonishing 78% in urban and 71% in the rural areas as compared to a near 50-50 private-public share in Sri Lanka. Private sector in that country compliments the public health sytem is revealed by the fact that 90-95% of inpatient care in Sri Lank still rests with the Public Sector. What was more chilling and revealing was the fact that even the public funded health care insurance schemes in India, like the Rashtriya Swasth Beema Yojana give more than 80% percent of it’s reimbursements to the private sector. In more simplistic terms, the money from Public coffers was finding its way into private lockers through a legitimate system of give and take. The health impoverishment, that is poverty brought about due to treatment of disease, has doubled in India in the last fifteen years. The revelation that out-of-pocket health expenditure in India accounts for 6.8% of household resources (and 12.1% of non food expenditure) in 2011-12 is a serious matter to ponder on by the country’s health policy makers.
It does not need rocket science to understand that health is a vital resource of a nation. A nation with healthy people has the capacity to think and act and therefore contribute intellectually and physically in nation building. It is hence imperative that the state should indulge in this persistent capacity building by promoting health care through the public sector. Unfortunately health ranks low in the imagination of our rulers. India contributes one of the lowest percentage of it’s GDP to health care in the world. At 1.3% health spending of its GDP, we stand lower than some of the poorest nations on the planet. Countries like Bhutan and Ethopia spend more on health than us. In the subcontinent there has been a persistent betterment of health statitics around us, as if we are stranded in a sea with healthy islands popping out all around. Data from the UN Population Division’s World Population Prospects reveals that Bangladesh has a better Infant mortality rate than us (31 versus 38 per 1000 live births). Nepal, has an even better IMR at 29 per 1000 life births and Sri Lanka has figures better than a number of Western countries (8 per 1000 live births). (I am not sure if it would be of any solace to know that Pakistan still has a higher Infant Mortality rate at 61 per 1000 live births!). The fact that even a war ravaged Iraq has an IMR of 27 per 1000 live births speaks volumes of the shambles in which the Indian health care system finds itself today. What is even worse is the fact that the health care delivery system in India has slowly but strongly passed into private hands as has been revealed by the eye opener in Lancet. Whether this is the result of a definitive effort on part of subsequent governments or whether there has generally been an apathy towards health as a state subject can be anyone’s guess.
Whatever the reasons, the strengthening of Private health care at the cost of the Public sector has disastrous long term results and we are already beginning to see the unfolding of this nightmare. Private sector (complimented by a non functional Public health sector) induces health impoverishment of an unprecedented nature. Sadly, Seema’s story is the story of every poor Indian family who is forcefully made to look towards the private sector in the absence of a robust and functional public health system. It cannot be over emphasised that in a country like ours where social stratification of economics and caste play a key role in vital events of life, health care delivery should be deeply rooted in the public sector. The private health providers have already usurped what is a wonderful health care delivery infrastructure on paper. Increase in health spending, formulating health policies of relevance (where diarrheal deaths are more important than deaths due to SARS) and renewing public confidence in the public healthcare delivery system through persistent scrutiny and accountability of the latter are some of the efforts which we need to induce on a war footing.
The private health provider has tasted blood and is here to stay. Whether we let them thrive at our cost or make them realise that they need to complement not surrogate the health care system in this country, is a choice we need to make urgently.
Prof. Shah Alam Khan, AIIMS, New Delhi (views are personal)