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February 2021

Infographics are a handy compromise between pure text articles and movies. They can be read at your own pace, like text, with the visual enhancement provided by images.

Here’s one on a popular subject: The routine health check up. It provides a guide to the perplexed on how to get the best value from the flood of choices on offer. (Use the landscape orientation if you are viewing it on a mobile phone.)

After you are done with it, there is additional reading — a long form article — on an important health topic, at the end of the infographic.



Why are we sleeping through the crisis in Indian healthcare?

Everyone talks about inflation; whatever the figure, healthcare costs outstrip the parroted number by a sizable margin. Unlike other purchases, health expenditure cannot be foregone or postponed, forcing most of us to cut back on food, clothing and shelter, the lack of which leads to poorer health and a vicious cycle of more health-related expenses.

India has the dubious distinction of being the world's most highly privatized healthcare economy. Five per cent of our gross domestic product goes to health; of this only 0.9% (less than 1/5) comes from the government's coffers. The rest is out of pocket. Compare this 80% with the 4% that the United Kingdom citizen pays and the 15% - considered monstrous - that the American forks out.

It is of great concern that a matter as important as our health is being left entirely up to the mantra of "market forces in an open economy".

The crisis

Currently, India has only one hospital bed for every thousand people against the WHO recommendation of one for three hundred. To meet this need, India has to add about 80,000 beds a year for the next five years or more.

The government has washed its hands of a large portion of its responsibility of taking care of its citizens' health. Almost 75% of all hospital beds are in the private sector; the share is larger still when it comes to medical technology. Public hospitals have witnessed a steady drop in the numbers utilizing their facilities, resorting to government-run hospitals only if destitute or after spending all their resources in the private sector.

What little there is in the treasury, is rightfully spent on public health measures such as immunization and nutritional programmes, and mother and child welfare; areas that the private sector is neither willing nor able to tackle.

The China-India success story is repeatedly cited as the role model for the open economy pathway to prosperity. Hidden in the hubris are some well-documented statistics that do not portend well for health care costs as development benefits trickle down through the population. Make a graph plotting the GDP/ capita against the expenditure on health. You will see a climbing slope from left to right ending in the mind-boggling US$ 8000/ capita of the United States. The figure does not plateau at any point. Satisfaction with services received does not parallel this slope all the way. It hits a sweet spot early and then flattens into a tabletop. In simple English, this means that as nations get richer, its citizens will spend increasing amounts on health care and can expect declining satisfaction as the amount increases. The percentage of Indian household income spent on health is projected to rise from 2 to 6% in the coming years. The more impoverished the Indian, the larger the chunk of his earnings that goes towards health expenses.

The Indian healthcare industry is pegged at Rs 85,000 crore per annum with an expected growth rate of 13% for the coming years. Though dominant, the private sector's participation is mostly in corporate ventures with non-profit organizations represented in small proportion. Profit-centred healthcare businesses have chosen to put their money mainly in tertiary care hospitals, stand-alone, high-tech diagnostic centres or single-speciality units. Primary and secondary care services are patchy and woefully inadequate.

There is no mechanism in India for monitoring demand and regulating healthcare facilities' distribution; "certificates of need" are not required for launching new units. Maldistribution is rampant. Similarly outfitted units are clustered in small areas, often down a single street in an urban area. An unhealthy, laissez-faire atmosphere prevails.

The massive out-of-pocket spending is a consequence of the severe shortage of third-party providers. Although India's growing middle class has been placing its hopes on insurance, it is still a fuzzy, distant vision. Less than forty million Indians are currently enrolled in insurance schemes. Many new insurance companies are from the private, for-profit sector and are very ginger about payments. The only segment of India that can rely on third-party coverage for their health expenses works for the government. Here too, there is considerable dissatisfaction with service quality. Seventy-five years after independence, the Indian welfare state offers minimal health benefits to its citizens.

An epidemiological transition will occur in disease patterns with increasing development: from infection to chronic illnesses of ageing and degeneration. India is not exempt. Two problematic aspects of the Indian scene are worth mentioning. There is very little accurate data about the epidemiology of diseases in India and no reliable figures for the costs of illness. Presumptions are made based on published Western data; a dangerous practice considering that the Indian has different disease patterns. Epidemiological data, such as is available, is restricted to infections in the disadvantaged and rural Indian. NCDs (hypertension, ischemic heart disease, diabetes, cancer and behavioural disorders) are notoriously expensive to treat. Small expenditures, repeated a few times confer large degrees of protection from infections. Not so with NCDs where the costs are high and prolonged. Poverty, thought to be protective against NCDs, does not confer any degree of immunity. We find that the rural, poor Indian is just as susceptible as the urban, wealthier ones.

Catastrophic health expenditures are expected in patients with NCDs. They are usually end-of-life episodes. Three-quarters of a person's lifetime health-related expenses can be spent in the last few months of life. Hospitalization for a major illness can wipe out a lifetime's savings. As stated earlier, 80% or more of this figure will have to be borne out-of-pocket. Catastrophic health expenditures are one of the leading causes of families being driven below the poverty line.

NCD-related expenses can be minimized only by an active and robust culture of prevention. Very little exists by way of promoting this ethos in India. It is not in the private sector's purview or vested interests. As a result, catastrophic illness is more intense and complicated in an Indian, who, typically, keeps postponing health visits and check-ups.

NCDs require life long monitoring and treatment, often with drugs taken for prolonged periods. The Indian generic drug industry has shielded the Indian consumer from the West's enormous prescription drug costs. India has accepted the WTO's stipulations on respecting intellectual property rights. The trade will be severely restrained in its ability to reverse engineer new compounds and deliver them to Indians at a fraction of the cost that the developed world pays. To enjoy the benefits of recent developments in pharmacology and therapeutics, Indians will have to pay more.

The mechanism of drug pricing is not transparent. The government mandates a Maximum Retail Price (MRP), but the formula by which this figure is calculated remains opaque. Pharmacies make indecent margins on sales and are the cash cows of the hospital industry.

Charges for professional services are likewise arbitrary and inscrutable. For a given service, costs can vary widely from doctor to doctor, and for the same doctor, from centre to centre and patient to patient, depending on the doctor's judgment of the patient's capacity to pay. If there is a third-party provider, charges are hiked up by unjustifiable margins. Professional fees are routinely indexed to room charges, even though the service delivered remains identical; a practice justified by the excuse of cross-subsidizing more needy patients by the wealthier.

Bills for a hospital stay are seldom itemized. Tariffs and charges are kept floating and arbitrary. Added to this is the widespread practice of collecting a large portion of the bill off-the-record as cash. Rarely can a patient get a complete explanation for the charge.

Unmonitored investment in health technology leads inevitably to excess capacity. Tests and interventions are over-utilized and extended to situations of doubtful value. Blood tests and scans are ordered with scarce regard to the tenets of evidence-based Medicine. The "Master Health Check" - which should include no more than half a dozen simple tests - commonly throws in the entire range of diagnostic technology that is at hand on the false premise that more is better. Waste abounds in the field of medical testing.

Faced with excess capacity and driven by the pressure to be commercially viable, unethical practices are rampant. Kickbacks to doctors for ordering tests are the rule. A tidy sum of money can be made from these commissions: a margin that rightfully belongs to the patient. The acceptance of such payments is repugnant and in violation of the fiduciary responsibility of a doctor.

Sadly, the wave of privatization has swept across medical education in this country. Alarming numbers of private medical colleges have come up across the length and breadth of India. They collect staggering sums of money as capitation fees despite having inadequate facilities and a severe shortage of qualified teachers. Certainly, graduates of these colleges will be looking at return on their investments and likely to charge premium fees for their services.

Those seeking redressal for unfair charges and poor service can take recourse to the consumer courts; however, the process has been bogged down by large caseloads. Litigation takes as long as five to seven years for resolution.

Patients and consumers of healthcare services are also to blame for this crisis. The steep rise in medical litigation in recent years leads predictably to the practice of defensive Medicine. Tests and interventions are ordered when unlikely to provide benefit, to forestall accusations of errors of omission; this will consistently drive costs up and do very little for improvement of quality of service. Trigger-happy patients induce defensiveness in the doctor and a loss of trust in the relationship.

Patient's expectations of modern Medicine are more than what can be delivered. The culture of a "pill for every ill" is well entrenched; modern, well-informed society refuses to accept any pain or discomfort and the inevitability of death. The demand from patients to undergo investigations can be overwhelming and unreasonable. To add to the problem, information access is universal and patients come loaded with ideas that are often out of context or even grossly incorrect.

Conclusion

Tackling these problems is a long, tedious and even dangerous task. It is unlikely that a Mohandas Gandhi will arrive on the scene to provide leadership. It is even more unlikely that a single strategy will provide a solution: the monster is hydra-headed. But, tackle it, we must. Today's technologies provide the means for concerned individuals to pitch in their might against the many issues that are at hand. We are not looking for a free lunch, but only for fairness in a situation where the consumer is kept mainly in the dark.