The Sickness of a Nation: Or, How You Should Never Be Too Eager to Grow Up

By Achyuth Chandra

I was less than 48 hours into my return to India after an absence of more than 5 years, during which time I had completed one degree, and began another. For the first time, I would be seeing the country I had been born in through (relatively) adult eyes, examining it through a filter of academic and general experience I had not been privy to on all my previous visits. One of the people I most wanted to listen and talk to in this new state was a cousin I hadn’t done either with for a long time, and so the first trip I took was to his college town in the eastern province of Assam. His appearance had changed, leaner and added goatee, and his character had changed too. He was still as charming, affectionate and kind as I remembered, but there was a subtle hardness to him now, an edge that I figured must have come from the 6 years he had spent training and practicing medicine in rural India. Despite his warning that I might see more than I can handle, I jumped at the chance to tour the hospital he worked and studied at, interested to know more about what had altered him in the last few years.

The first impression I had of the hospital was positive, beyond all expectation. It was an impressive building, with front walls painted a pristine white, glass and steel criss-crossing across its architecture. It seemed spacious, expensive, and clean, bustling with the activity of white-uniformed professionals I had come to associate with hospitals in North America. I was ready to dismiss my cousin’s warning as the cynicism of the over-worked, until he led me inside the hospital proper. As we passed the Staff Only sign on the door, I realized perhaps his warning had been an understatement. The walls and floors were covered in grime and dirt, desperate patients of skin and bone clothed in rags were lying on the floor waiting for care (how many hours had they been there?), the ever-present reek of disinfectant was tinged with the heavy aftertaste of human waste and blood, and cries of pain and agony echoed through the dimly-lit halls. It felt at the time as though I was walking through a nightmare, and the tales my cousin was telling me did not help the feeling; tales in which, faced with such a severe lack of resources, staff at the hospital were forced to re-use needles and sutures or fashion them out of improvised material; in which the dying were forced to wait hours for treatment, or refused it outright; where, due to a crippling absence of seasoned doctors, interns and students were forced into complicated procedures above their level of experience with disastrous outcomes. At the end of my visit, I was shellshocked, traumatized not only with what I had seen but with the nauseating comprehension that this was the norm for dozens and dozens of millions of people in India.

Healthcare is a complicated issue to understand, and even harder to discuss. Inevitably the conversation becomes emotionally charged, and the actual topic at hand is forgotten, in lieu of a focus on heated differences in opinion on ethics and macro-economic policy. In light of that, let me strip myself of some emotion and present the basic facts pertaining to the discussion. The private healthcare sector in India today remains what the vast majority of the Indian people use. In rural areas, approximately 63% of people use private over public healthcare, while in urban cities that figure jumps up to as high as 70%. This discrepancy varies wildly from state to state, but as a whole, it is obvious to see that the population trust and use privatized healthcare more than the public sector, despite it also costing much, much more. In 2014 for example, the average cost of hospital care by a public utility was approximately Rs 6 000 (~90 USD), while at a private clinic that same year, the average cost jumped to more than Rs 25 000 (~375 USD). Combining these statistics with the fact that it has been estimated less than 20% of Indian citizens have any form of health insurance (in interesting contrast to China, whose insurance penetrates roughly 95% of the population) , it is not difficult to see why more and more Indian families (both rural and urban) are being forced to dip into their life savings in order to get the minimum care they feel they deserve. These healthcare payments are pushing households into severe poverty every year, with a recent estimate that more than one-third of poor families in India had incurred ‘catastrophic health expenditure’.

The obvious next question to ask is, why do people feel forced to resort to expensive private care, when (especially for the very poor) public care can be had for vastly cheaper sums of money? The answer that most Indians point to is the lowered perceived quality of care that public institutions provide. Despite government initiatives such as the National Rural Health Mission, rural areas in India continue to struggle to attract experienced healthcare professionals from urban markets, leading many public healthcare utilities to be staffed by inexperienced interns, forced into rural practice as part of their schooling. In addition to the lack of experienced staff, public institutions also struggle with longer wait-times, limited resources and irregular working hours. One cause of these factors is a severe lack of funding. Out of the 190 countries the UN collects information on health expenditures from, India was ranked 175th, currently devoting 1.4% of their GDP to public health; comparable to war-torn Yemen (1.3), and even less than hurricane-ravaged Haiti (1.6). To put this figure in further context, note that the average expenditures for the least developed nations is 1.9%, while for heavily indebted poor countries, the figure increases to 2.5%.

The lack of government funding might be acceptable if the caliber of the private healthcare market was high, as some suggest it is. In a recent policy research paper by the World Bank Development Research Group, Dr. Jishnu Das and co. presented direct evidence on the quality of healthcare in low-income settings. They did this by ‘auditing’ a representative sample of public and private healthcare providers in one state in India, by sending out a trained collection of standardized patients, and therefore objectively testing the response. Three main findings were reported in the study, the first was that the private healthcare clinics staffed mainly unqualified professionals, but at the same token they spent more time with patients and checked off more essential history and examination items than public providers, with no major differences in quality of treatment and diagnosis. Second, doctors with both private and public practices exerted higher effort and were more accurate with their treatment recommendations in their private work. The third finding was that there was a strong positive correlation between quality and prices charged in the private sector, whereas there was no such connection in the public sector. Dr. Das concludes that market-based results in an unregulated private sector can provide better incentives for the provider and thus better outcomes for the patient than a more centralized, regulated setting in the public sector. Though he admits the quality of care in both sectors is low, he points to the demonstrated difference in provider effort to suggest that, even in the presence of free public healthcare, people might still prefer private clinics.

However, there are other experts who would disagree with his diagnosis, and point instead to the rampant and insidious corruption associated with the private healthcare sector. A recent report in the BMJ by Arun Gadre, from Kolkata, exposed the extent of this malpractice. He interviewed 78 doctors (of which the overwhelming majority were private practitioners) and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions are commonplace. Examples of ill treatment included gynaecologists performing sonography without necessity in pregnant women, then constructing false reports of abnormalities, or a referring general doctor advising a large series of laboratory tests despite no indications of illness. In one particularly damning anecdote, Dr. Gadre describes being told of pathologists being paid by referring doctors to label healthy patients as having diabetes so that they are dependent on the referring doctor for life (and thus provide a steady stream of income). In Dr. Gadre’s report, in contrast to Dr. Das, he identifies the “commodification of healthcare” as the primary cause of these systemic issues, and opines that a universal healthcare with heavy social regulation is the answer to India’s woes (though he admits that the political will required for this is large).

Still others would deny that there is a problem to either sector at all, and would point to the improvements India has made in the last two decades in the presence of malnutrition, the incidence of disease, and the rate of infant mortality (among many other outcomes) as an indication that India is in fact improving in leaps and bounds. In an article in the Harvard Business Review, for example, Dr. Vijay Govindarajan argues that American hospitals should in fact be learning from the techniques and adaptations of Indian hospitals; in the paper, he suggests that many of the items of common complaint about the healthcare of India are in fact features and not bugs, designed to cut cost dramatically compared to the American alternative. He points to the frugality of Indian hospitals, who shorten the lengths of suture strings, re-use steel clamps used in open-heart surgeries, and order smaller maternal beds; he views the over-utilization of interns, nurses and students as essential ‘task-shifting’, freeing up experienced doctors to do more important procedures; he suggests that the lack of rural hospital resources allows them to specialize in what they need for diagnosis, routine treatment and follow-up care while diverting cases with more attention required to urban centers, thus creating a more efficient model of healthcare delivery. At first blush, this argument holds a lot of sway, but much like the hospital I visited, the initial impression falls away under closer examination. Govindarajan argues that a similar quality of care to American hospitals can be achieved through these methods, but to arrive at this conclusion he only examines 9 of the premier hospitals in India (all of them in the private sector). Does the frugality, the task-shifting and the lack of all but basic essentials provide a high quality of care in the vast majority of Indian hospitals, for the vast majority of Indian people? I believe the plateaued rate of improvement of every relevant healthcare outcome in India, compared to other developing nations, point to no.

So, ultimately, what is the reason for the failure of healthcare in India? Perhaps it is in the innate commercialization of privatized healthcare, leading to a system of corruption and malpractice. Alternatively, it could lie in the fundamental failures of public healthcare to function without the incentives of unregulated wages. Could it be in the lack of government funding, leading to the degradation of quality in both the private and public sectors, and in the subsequent lack of penetration of health insurance? Or maybe there is no failure at all!

To me, any, and even all of these answers would be welcome, because all these answers come with things that can be done, policy decisions that can be implemented to reverse those outcomes. But as I walked back out of the dusk-lit hospital halls with my cousin on that sticky, summer day, another possible truth arose unbidden and unwanted in my freshly-adult mind. Maybe India just has too many people and too little resources to do anything more significant towards combating the paralyzing issues it faces.

Maybe, this is simply the best we can do.

References

  • International Institute for Population Sciences and Macro International. “National Family Health Survey” (PDF). Ministry of Health and Family Welfare, Government of India (2007). pp. 436–440.
  • Chauhan, Chetan. “Most Indians Prefer Private Healthcare Services over Govt Hospitals.” Http://www.hindustantimes.com/. N.p., 05 July 2015.
  • Johar, Zeena, and Xue Ying Hwang. “Despite Their Economic Strides, China and India Lag on Health Care.” Yale Global. N.p., 17 Dec. 2015. Web. 14 Oct. 2016.
  • Sekher, T. V. “Catastrophic Health Expenditure and Poor in India: Health Insurance Is the Answer?” International Institute for Population Sciences (2011): n. pag. Print.
  • International Institute for Population Sciences and Macro International. “National Family Health Survey” (PDF). Ministry of Health and Family Welfare, Government of India (2007). pp. 436–440.
  • The World Bank. “Health expenditure, public (% of GDP) [Data file]”. World Development Indicators (2012). Retrieved from http://data.worldbank.org/indicator/SH.XPD.PUBL.ZS?
  • Das, Jishnu, Alaka Holla, Aakash Mohpal, and Karthik Muralidharan. “Quality and Accountability in Healthcare Delivery.” World Bank Development Group (2015): n. pag. Web.
  • Devarajan, Shanta. “The Inconvenient Truth about Public and Private Health Care.” Brookings Institute. N.p., 29 Nov. -0001.
  • Govindarajan, Vijay. “Delivering World-Class Health Care, Affordably.” Harvard Business Review. N.p., 18 Aug. 2014.
  • Balarajan, Yarlini, S. Selvaraj, and S. V. Subramanian. “Health Care and Equity in India.” Lancet. U.S. National Library of Medicine, 05 Feb. 2011.

About the Author

Achyuth Chandra

Achyuth Chandra is now pursuing an honour major in Cognitive Science with a minor in Political Science at the University of McGill and planning on beginning a Master’s degree in counseling psychology in the fall of 2015. He is actively involved in the McGill Debate Team, several creative writing organizations in McGill (including VP of the Paper’s Edge), and plays tennis and boxes on his down time.


Posted in: All Publications 2016

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