Pathetic state of clinical care

Union Health and Family Welfare Minister, Jagat Prakash Nadda, deserves kudos for presenting a disturbingly accurate picture of the country's state of healthcare in Parliament while presenting the national health policy. The document is reasonably dependable, though not comprehensive. It provides a complex background of the industry, dominated largely by a profit-motived private sector as successive governments faltered in providing proper healthcare to its people. There is little hope that things will change for the better. The government admits that the private healthcare industry is complex. But, it offers little towards a solution. Maybe, the damage has already been done by the persistent neglect of the sector over the last six decades leaving the field at the mercy of a corrupt and profiteering private sector. The policy document does not dig into the details about how the private sector succeeded in the complex business while the government failed despite its good intentions.

The document doesn't analyse why the public sector drug companies failed to survive while private sector pharmaceutical firms are a roaring success, making fat profits, corrupting drug administrators and exporting billions of dollars worth generics annually; why patients are increasingly losing faith in government hospitals and rushing to private healthcare centres even at formidable cost. A visit to 'out-door' departments (OPD) even in hi-profile All-India Institute of Medical Sciences (AIIMS) or Safdarjung Hospital, both in Delhi, will show how a harassed-looking specialist physician is subjected to examine 70 to 80 patients per sitting on a given day. A patient may feel very lucky to spend three-four minutes with a doctor, after waiting for hours for his or her turn. In fact, the Central and state governments have failed to operate their hospitals and clinics in a way that would improve the confidence of both patients and physicians in the system. In Delhi, nearly one in every two doctors suffers from violence at public hospitals, reveals a recent Maulana Azad Medical College (MAMC) survey that covered 169 junior and senior residents, working mostly with Lok Nayak and GB Pant hospitals, attached to MAMC. Last week, several thousand public hospital doctors in Maharashtra struck work in protest against regular manhandling from disgruntled patients and their kin. The environment around state healthcare centres is getting messier by the day.

On the other hand, patient-exploitation by private hospitals doesn't seem to trouble the government. Thanks to the lack of imagination on the part of the Insurance Regulatory and Development Authority of India (IRDA), health insurance by private individuals has become a joke. Private hospitals make sure that the insured sum for hospitalisation and treatment never fully covers a patient's 'actual' treatment cost — from routine cataract surgery to heart bypass and stent implant. Both health insurers and policyholders bleed while only private hospitals and clinics make money. The IRDA has utterly failed to achieve its primary objective to protect the health insurance industry and policyholders.

According to the background papers of the healthcare policy, the private healthcare industry is currently worth $40 billion (Rs.280,000 crore) and is projected to grow sevenfold to $280 billion in the next decade. The healthcare industry is projected to grow annually from the present 14 per cent to 21 per cent. Instead of playing a more direct role to ensure healthcare for all, the government will work as a facilitator to the private sector healthcare industry's growth. Paradoxically, the document gives more credit to the previous administration than the current BJP-led government for "heavily" investing "in the last 25 years in building a positive economic climate for the (private sector) healthcare industry. Amongst those measures are lower direct taxes; higher depreciation in medical equipment; tax exemptions for five years for rural hospitals; and customs duty exemptions for lifesaving equipment; preferential and subsidised allocation of land, subsidised professional education in government institutions; and provision for 100 per cent FDI. This active policy enabled the private healthcare industry attract over $2 billion in FDI in 2012-13."

However, the parliamentary standing committee on health is not impressed. It has strongly criticised the government for starving the health sector of much-needed funds. In its report on demand for grants for 2017-18, the committee noted that the allocation for the National Health Mission (NHM) fell far short of what was needed to execute the announcements in the Budget. Some state health budgets for 2016-17 have registered declines compared to 2015-16 such as in Assam, Chandigarh, Daman & Diu, Karnataka, Manipur, and Puducherry. And, many other states have registered only a single digit increase in percentage terms, the committee noted. While the new healthcare policy recognises the "need for the government to actively shape the growth of this sector so as to ensure that it is aligned to national health policy goals, especially with regard to equity, access and financial protection", the task seems to have been left mostly to the private sector "to fulfil its mandatory obligations in return of myriad benefits provided by the government. There is also a need to ensure that the basic policy structure, especially as regards costs, standards and regulation is not unduly influenced by the requirements and perceptions of industry." The policy confessed that the government sector in health does not cover even 30 per cent of the population. "Over 70 per cent of ailing population in rural areas and almost 80 per cent in urban areas utilise private facilities" while "majority of the private healthcare enterprises are Own-Account-Enterprises (OAEs), which are household run businesses without the regular hiring of a worker..There are major ongoing efforts by the government to streamline the OAEs within the corporate sector and to regulate them."

The policy expressed concern over the variability in the quality and rationality of care currently provided by the private medical sector. "There is evidence of supplier-induced demand and lack of standard treatment practices, leading to aberrations such as unnecessary injections, irrational treatment regimens and excessive medications being provided in the private medical sector." The union government's share of healthcare expenditure is only Rs. 365 per capita (0.40 per cent of GDP) while state governments' is approximately Rs 677 per capita (0.75 per cent of GDP). The total public spending on healthcare in 2013-14 was only 1.15 per cent of GDP.