The Cost of a Sick Nation

WHEN JYOTISH KUMAR Chandravanshi’s infant son Aryan complained of nausea on September 5th, the 31-year-old, who lives in Vasant Gaon, took him to a doctor in the nearby tony Delhi locality of Vasant Vihar. The doctor prescribed Paracetamol and another drug whose name the Bihar-born driver doesn’t remember. When the boy’s condition worsened the next day, his wife took him to another doctor, also in South Delhi, who asked her to take Aryan to the government- run Safdarjung Hospital after merely glancing at the feverish child whose lips had begun to turn blue. By the time Chandravanshi got the call at work and reached the hospital during rush-hour traffic, his wife was fighting back tears and barely managed to break the news to him: their second son had breathed his last during the long auto ride, and was declared brought dead by doctors. “Private doctors often don’t express the urgency of the situation because they think we don’t understand medical terms. They also turn us away from their clinics even without offering first aid because they think we can’t pay,” Chandravanshi says ruefully, sharing that Aryan would have turned three on November 14th. “And I don’t have the time and energy to probe what went wrong and why my son died the way he died.”

If this situation captures the predicament typical of the urban poor or those from the lower middle class as regards healthcare access, the case of 18-year-old Suraj Roy offers a glimpse into the lives of those who need specialised care in our villages and small towns. In a freak accident, Roy sustained head injuries a fortnight ago when his scooter skidded on a rough patch on the road and fell on his way to work in Rudrapur, a bustling town in Uttarakhand. Suraj’s parents, Bakul and Sahadev, both daily-wage labourers, were told at the local government hospital that it was not equipped with enough diagnostic machines. Suraj was then rushed to a government hospital in Haldwani, some 30 km from Rudrapur. “Here, they did not even touch him. They told us the machines needed for him were spoilt and asked us to take him to some other hospital,” says Bakul, the mother. The next door they knocked was that of a private hospital where Suraj was just kept on oxygen all night but nothing else was done. The hospital charged them Rs 45,000 for that night. It was in the next hospital, also a private one in Haldwani, that Suraj was operated upon after an MRI was done. As hospital costs soared, Sahadev collected his son’s reports and made a trip to New Delhi, around 250 km from Haldwani, hoping that he could get him admitted to a government hospital for the required treatment. He returned crestfallen because there was no bed available in some of the most prestigious government hospitals. Suraj, whose diagnosis said ‘head injury (right frontal contusion) with facial injury’ was still in ‘critical condition’. The doctors had warned them that the hospital expenses could go up to Rs 20 lakh. The family had given all they had. “We now take donations from fellow villagers. I don’t know what to do. He is still unconscious but the doctors say he was improving,” Bakul says, emphasising that each day starts with deep anxiety.

While government hospitals are under-equipped, under-staffed, and under- funded, privately run hospitals routinely resist any effort to regulate the exorbitant sums they charge for procedures and for services. Dr Puneet Bedi, a consultant in gynaecology at Indraprastha Apollo Hospital, who has closely watched the country’s healthcare scenario, offers, “Government hospitals are a British legacy and were designed to treat only a small fraction of India’s population. The situation continues… If ageing parents are admitted to private hospitals, the children end up fighting over who would pay the bills because that would be much more than any fortune they are going to inherit.”

It is a tongue-in-cheek statement, yet it reflects the biting reality: that even upper middle class and affluent families—with the probable exception of the super rich who are only happy to flaunt the sums they pay for their parents in hospitals in cocktail banter—find hospital expenses far too high for comfort. For a country that is considered one of the fastest-growing economies in the world, its public health system is plagued with numerous odds and the numbers tell the harrowing tale: According to the ‘Global Burden of Disease’ study, published in The Lancet, India ranks 154 out of 195 countries in healthcare access. Out of nearly a million allopathic doctors for 1.3 billion people, only less than 10 per cent work in the public health sector, according to the National Health Profile 2017. According to reports, India has only one allopathic doctor in government hospitals for 10,189 people; one government hospital bed for every 2,046 and one state-run hospital for every 90,343 people. With death in government hospitals hurting its image, the ruling Modi Government has announced that it will invest 2.5 per cent of its GDP in healthcare by 2025 from 1.2 per cent of its economic output currently.

India has the lowest public healthcare expenditure of all the BRICS nations (Brazil, Russia, India, China and South Africa)—South Africa spends around 8.8 per cent of its GDP on health; Brazil spends 8.3 per cent and Russia 7.1 per cent on health. In its November 14th issue, The Lancet has termed the declaration an ‘embarrassment’. It added, ‘We are disappointed by the lack of ambition of Prime Minister Modi’s government to invest only 2.5 per cent of its GDP into health care by 2025, when the global average for countries is about 6 per cent.’ Incidentally, India faces a huge challenge of quackery and a WHO report pointed out last year that only one in five doctors in rural India is a qualified doctor. The report stated 31.4 per cent of the ‘doctors were educated only up to Class 12 and 57.3 per cent doctors did not have a medical qualification’. According to a Brooking India paper of 2016, as many as 18 per cent of government Primary Health Centres were entirely without doctors and many others faced huge shortcomings in the way they functioned. Though The Lancet found the objectives of the new National Health Policy 2017 disappointing, the Modi Government had pitched it as a milestone, a word used by Health Minister JP Nadda, who claimed that this policy seeks to move away from sick-care to wellness, with a thrust on prevention and health promotion. “While the policy seeks to reorient and strengthen public health systems, it also looks afresh at strategic purchasing from the private sector and leveraging their strengths to achieve national health goals,” he said.

A senior Health Ministry official regrets that governments, be it in state or at the Centre, have done little to improve the public health infrastructure in the country, and in the process given rise to massive economic costs for the country. Though comprehensive studies on the economic costs of poor public healthcare and overly commercialised private hospitals are in order, a few independent research studies suggest that the country pays dearly in terms of potential job losses and productivity. The fact that infant mortality rates, despite showing improvement, are still higher than many poorer countries, is an indication of the extent of the damage incurred in the world’s largest economy where two children younger than five die every minute. The health of an average Indian is worse than those in other SAARC countries, except Pakistan, thanks to the poor public expenditure on health that has led rise to large-scale inequities on access to healthcare. Ideally, economists and health experts aver, India’s public expenditure on health has to be upwards of 5 per cent of the GDP to achieve the lofty goals outlined in National Health Profile 2017 and to ensure universal health care for all its citizens in less than a decade.

While government hospitals are under-equipped, under-staffed and under-funded, privately run hospitals routinely resist any effort to regulate the exorbitant sums they charge

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Such an effort will also help cut the costs of being a sick nation.

According to a World Bank study that looked at the costs of poor health parameters, inadequate sanitation alone caused ‘India considerable economic losses, equivalent to 6.4 per cent of India’s GDP in 2006 at US $53.8 billion (Rs.2.4 trillion)’. This report from the Water and Sanitation Program (WSP), a global partnership administered by the World Bank, ‘analysed the evidence on the adverse economic impacts of inadequate sanitation, which include costs associated with death and disease, accessing and treating water, and losses in education, productivity, time, and tourism’. The findings of the survey, done in 2010, were based on 2006 figures. The magnitude of losses due to sanitation may have only risen in later years. Worse, out-of-pocket expenses of people who are forced to rely on private hospitals because of lack of resources in government-run ones have only gone up, according to data available with the Government.

A report by the Ministry of Health has put losses due to tobacco- related deaths as high as Rs 1.04 lakh crore in 2011 alone. It was more than 1.16 per cent of the GDP that year. Ironically, the total central excise revenue from all tobacco products of that fiscal year was only 17 per cent of the economic costs of tobacco. Though India is committed to fulfilling its obligations under the Framework Convention For Tobacco Control (FCTC), it has not done enough in the name of protecting tobacco farmers. A Health Ministry official based in Delhi says the Centre can’t “hide under” that excuse forever, and instead needs to look at ways to rehabilitate them. Tobacco, according to WHO, kills half of its users. India was one of the earliest signatories of the FCTC. The Indian law — Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act 2003 — envisaged slashing space for tobacco in the public sphere. Yet, there is proof that successive governments have capitulated on promises. For instance, public sector insurer Life Insurance Corporation of India has a stake in tobacco major ITC, India’s biggest cigarette maker. Meanwhile, Union Health Minister JP Nadda tells Open in an interview that his Ministry has taken “commendable” steps for tobacco control “such as enhancing of the size of specified health warnings on tobacco products by covering 85 per cent of the principal display area of the packages of tobacco products with effect from 1st April 2016 and by regulating the depiction of tobacco use in films and television”.

Soumya Swaminathan, who met Open at the office of the Indian Council for Medical Research, has no doubt about the need for India to comply with FCTC requirements. Swaminathan, former secretary at the Ministry of Health, is on her way out as director general of ICMR since she is joining the WHO as its Deputy Director General for Programmes. “Tobacco is one of the biggest risk factors for so many health conditions. The Health Ministry’s goal should be to do away with tobacco use. The tobacco lobby is a strong lobby and there is always a constant battle, but WHO’s viewpoint would be the same that we need to eliminate tobacco, nothing short of that.” She goes on, “We have to also look at rehabilitating tobacco farmers and people who roll bidis.” She agrees that livelihoods have to be protected. “But that does not mean we carry on with tobacco production. We need to think of what are the alternate crops they can grow… They can be trained for something else. There will be enough NGOs willing to take up that work but there needs to be a will.” Though excise revenues from tobacco sale are much lower than the cost of tobacco use, the political establishment has taken no bold steps to either curb tobacco use nor incentivise alternative farming solutions.

Lack of proper accountability in healthcare also adds to the woes of the health sector. Experts feel that though NHP 2017 talks of public-private partnership, it will cater mostly to specialised healthcare and not basic healthcare facilities, which are a luxury to millions in rural India. Alongside the poor performance of rural health initiatives and a crumbling village health centres network, there is a worrying trend: a spurt in hypertension and diabetes in the hinterland just as it has been rising in the cities. Swaminathan, like many other health specialists, links it to changing dietary habits. A survey by the Hyderabad-based National Institute of Nutrition has shown that carbohydrate intake is high in India and this is true for the poor as well, she says, adding this is a phenomenon linked to subsidised rice and wheat. “Through PDS we have rice or wheat with very little animal protein or high quality protein. There is an urgent need for dietary diversity,” she says. She suggests one way of doing that is by incorporating more types of food like millets and pulses into the PDS. “If we can go one step further, we could make sure fruits and vegetables are available through fair price shops,” she rues. She gives the example of Moringa “which grows everywhere but is rarely consumed”. The disease burden due to child and maternal malnutrition in India is 12 times higher per person than in China in 2016, according to a paper published this month titled ‘India State-level Disease Burden Report and Technical Paper’. Malnutrition, according to reports, is responsible for 15 per cent of the total disease burden according to latest data available.

Communicable diseases continue to remain a major concern for India with India missing earlier targets to eliminate diseases such as kala-azar and measles. The Health Ministry had set a deadline for 2010 to eliminate the former and then revised it to 2015, yet there are thousands of cases of the parasitic disease in India. India has also not made much headway in fighting tuberculosis, which is also a killer disease thanks to its new variants including drug-resistant ones. Swaminathan, an expert in the field, says, “The biggest challenge is getting the private sector on board [to contain TB]. We have not succeeded in that on a large scale. In fact, it’s a timely opportunity for private practitioners because the [anti- TB] programme now has advanced molecules diagnostics for rapid diagnosis that can be offered free to all patients. In addition, we have [devised] a daily regimen and drugs that can be offered free. So now there is a mechanism and a path for the private sector to come on board. All they need to do is notify every patient, follow every patient. They don’t have to refer every patient to the government.”

Unfortunately, despite the heavy toll taken by illnesses, India’s research is not up to the mark. While there is resistance to enhanced spending from some quarters in the Government that are sceptical about its direct benefits, experts belive the benefits of medical research cannot be quantified easily. In his analytical piece titled ‘Medical research in India and the rise of non-communicable diseases’, health sector expert Vageesh Jain has explained why enhanced spending in health research have multiple benefits for a country. He writes quoting the 2012 WHO report, ‘No Health Without Research’, that research in the long term strengthens health systems and improves equitable distribution of high quality health services. For her part, Swaminathan blames the scientific community for not lobbying for support. “Overall, what research brings to a country and its economy is still not very well understood by many policy makers and politicians. I would place the blame entirely on scientists. We have not been able to capture the imagination of people. We have not been able to communicate the benefits of science. Once people see a rocket in space, they feel such pride. That translates into support for ISRO. The same achievements have been made in other spheres, like agriculture, the pharmaceutical industry, biotechnology, medicine but we have not communicated those. They may be incremental things, unlike a rocket taking off, which appears dramatic. It doesn’t happen the same way in all fields of science. A new vaccine or drug is developed once in a while. It’s a question of communicating.”

Swaminathan gives the example of the US where high spending on health research has proved to be highly effective in combating rising non-communicable diseases (NCDs)— those linked to lifestyle—and in reducing economic costs.

Poor nutrition, imbalanced diets and habits such as smoking and drinking have contributed immensely to a rapid rise in NCDs in India. According to a report, NCDs (which include cardiovascular diseases, cancer and diabetes, among others) and mental illness will cost India $4.58 trillion between 2012 and 2030. The estimate was given in a report published by the World Economic Forum and Harvard School of Public Health. The causes range from early retirement, negative expectations regarding employment and reduced productivity. ‘The disease burden also leads to increase of expenditure for health system, individuals and households,’ the report said. Cardiovascular diseases ($2.17 trillion) and mental health ($1.03 trillion) are expected to be the major contributors to the economic impact of NCDs, it added. Swaminathan hopes the ambitious nutrition mission being steered by Niti Aayog may be able to bridge the gap in addressing nutritional requirements of people. “[So far] there is no department of nutrition, so no one was accountable for nutrition. There is a Ministry of Agriculture, which looked at crops and seeds. There is the Women and Child Ministry which looked at aanganwadis, pregnant women, etcetera. The Ministry of Health is concerned with nutrition of mothers and children but does not have any direct role. It is all very scattered. The nutrition mission should bring all these pieces together.”

According to her, the minimum benchmark for India’s health budget should be 2.5 per cent of GDP up from 1.3 now, five per cent of which should go for research. Dr Bedi is of the view that regulating healthcare costs in the private sector is a must for ending what he terms “organised loot” by private hospitals which he says behave like the “mafia”. For his part, Nadda hopes various initiatives the Centre has rolled out to bring down out-of-pocket expenses of people through its flagship programme—National Health Mission—will bear fruit. “The [new] initiatives taken by the Central Government (to make medicines more accessible) not only provide drugs at no cost or subsidised cost but also manage the drug procurement and inventory,” he says.

Of course, there some rays of hope, thanks to the Centre’s new initiatives. Yet, worries abound. In a country where basic health access is a luxury for the majority, where private-sector treatment can turn families bankrupt, where regulation and accountability in healthcare are still a far cry, trillions of rupees and valuable lives could be lost for not acting swiftly. The sickly Indian health sector is in need of a timely cure.

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Union Health Minister JP Nadda’s Interview. Click here to read

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Ullekh NP and Amita Shah