Why the Indian patient is caught between the devil and the deep sea
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First it was Gorakhpur. Now it is Farrukhabad. The death toll in Uttar Pradesh’s government hospitals—from what appear to be preventable causes—has been mounting over the past month. Similar incidents have been reported from other states, pointing to the deep state of crisis in India’s healthcare system.
The rot in public hospitals has been apparent for some time now. Data from a National Sample Survey Office (NSSO) report conducted in 2014 showed that the majority of Indians prefer to consult private practitioners rather than public hospitals. A comparison with the earlier NSSO round shows that the proportion of patients using public facilities has increased only marginally in rural areas despite the expansion in rural public health facilities financed by the National Rural Health Mission (NRHM) over the past decade.
Those who do visit public hospitals often do so out of compulsion. A 2013 survey conducted by the Centre for the Study of Developing Societies (CSDS) showed that 47% of the people who visit a public hospital do so because they have no other choice. Among those who visit public hospitals despite having the choice of private care, most do so because of affordability. This is despite the fact that 52% of the respondents thought that the quality of government hospitals had improved compared to earlier.
Does the poor state of public hospitals suggest that the answer to India’s healthcare woes lies in private care? Several policymakers have suggested so in the wake of the Gorakhpur tragedy. While this may seem an attractive solution in the face of the crisis in public healthcare, the evidence in favour of private medical care is thin.
Private medical care is more expensive, often involving unnecessary tests and procedures, and is on average no better than public care in much of the developing world. This suggests that the average Indian patient is stuck between the devil and the deep sea when it comes to healthcare.
According to a 2016 World Health Organization (WHO) report, 57.3% of allopathic doctors in India do not have a medical qualification. In rural areas, this number is greater than 80%. How does one reconcile this with rising footfalls in private clinics? A World Bank paper by Jishnu Das and others offers some answers. The paper is based on an audit of private and public health providers in rural Madhya Pradesh. The authors found that even though private-sector doctors were much less qualified than public-sector ones, they were more likely to give adequate time to patients and even performed better in fulfilling a standard diagnostic checklist.
However, this study is based on outpatient consultation and does not account for in-patient services.
As the NSSO data shows, the gap between the shares of patients using public versus private care is much smaller when it comes to hospitalization. One reason for this might be increasing costs of private medical care, which have driven up hospitalization costs sharply over the past decade . Private care may often also involve unnecessary diagnostic tests and even surgeries that may be discouraging some patients. As a Mint article by HowIndiaLives had pointed out, caesarean deliveries were much more common in private facilities than in public hospitals.
The expansion of the private sector in healthcare has taxed the weak regulatory capacity of developing countries, which has often led to poor outcomes. A 2012 review paper by Sanjay Basu of the department of medicine, University of California, San Francisco, and co-authors did not find any evidence to support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector in developing countries.
Relying on private care can also drive up costs of hospitalization further, adding to the vulnerability of households impacted by health shocks. A 2016 Brookings India report based on an analysis of NSSO data noted that “catastrophic health expenditures have risen significantly over time, for all three threshold levels (health expenditure exceeding 10%, 25% and 40% of usual consumption expenditure), and across both rural and urban India”.
While medical insurance is often touted as an answer to rising costs, high premiums often leave out the poor and the needy. And state-subsidized insurance schemes do not seem to be working well. A January Economic and Political Weekly research paper by the economists Soumitra Ghosh and Nabanita Datta Gupta showed that the flagship medical insurance programme, Rashtriya Swasthya Bima Yojna (RSBY) has failed to cover an adequate number of poor households. More worryingly, the research showed that the programme had hardly any impact on financial protection.
Given the lack of quality and assured healthcare in the country, it is not a surprise that health is emerging as a major concern, especially among India’s youth.
India’s political class has failed to respond to these anxieties so far. But this is also an opportunity for political entrepreneurs.
As the chief economic adviser to the finance ministry Arvind Subramanian pointed out recently, the only political party that has made healthcare a political priority is the most nascent party in India’s political firmament: The Aam Aadmi Party. But if AAP’s experiment with neighbourhood clinics inspires other political parties, it may change the face of healthcare in the country, he argued.
Till the time India’s polity changes, the average Indian patient is unlikely to have assured access to quality healthcare.
This story is based on survey data shared exclusively with Mint. Sanjay Kumar is professor and currently director of CSDS and Pranav Gupta is a researcher with Lokniti CSDS.