With World Health Day just past us, (April 7) we in India might have something to cheer. Government initiatives like the rural medical course and health insurance for the poor (including specialist care) are good, fresh ideas. But they need the right heads to think them through. A high-profile specialist in Bangalore wrote some months ago: “Millions will still perhaps be living in slums with no running water or sanitation, but when they are unwell, they will have access to high-tech health care with dignity, like in the developed world.” He feels that health care is a complicated business, best handled by people like himself.
Many corporate hospitals endorse this idea and have started expanding their empires. They will build mega hospitals in more cities and towns, train more specialists, increase their bed-strength and wait eagerly for patients to fall ill. With cheap health insurance paid for by the government, they are assured of their clientele and applauded for their altruistic service to the poor. Privatisation of the entire health system is what they would like, with the government merely bearing the financial burden of providing insurance. They also want low lending rates from international funding agencies, exemption of import duty for expensive medical equipment and subsidised rates for land to build their hospitals. The government may actually go along with this idea and thus shrug off its own responsibility in the delivery of health.
Specialists' understanding
My reservations about turning health care into a private, corporate industry stem from the fear that these experts do not understand health. What they understand are the diseases that fall within their specialist domain and which they are trained to cure. These comprise less than 20 per cent of all illnesses in our country. They should continue their excellent work in what they know best and not demand that they be made health care providers for the entire country. That will be much like an instant-noodle company being asked to provide nutritious meals for school children. I hope my esteemed specialist colleagues will not take offence but there can be no mincing of words when the health of an entire nation is at stake.
Four-fifths of diseases in India are caused by five factors: lack of clean drinking water, insanitary living conditions, pollution of all types, inadequate nutrition and stress. Typhoid, malaria, dysentery, TB, skin and lung infections – which kill millions every year – are produced by insanitary conditions. Stress causes heart disease, high blood pressure, peptic ulcers, asthma, allergy and mental illness. Although many see stress as a privilege of the upper class, the poor are subject to unrelenting anxiety and stress caused by hunger, homelessness, unemployment and the loss of dignity. No Art of Living or Stress Management course will give them relief. To wait for them to fall sick and then rush to their doorstep with high-tech cures is as insulting as throwing a piece of chocolate to a hungry stray dog.
Simple measures can prevent 80 per cent of diseases afflicting our people. Every developed country has dealt with them decades ago and done away with most infectious and communicable diseases. India, which has built steel plants, huge dams and National Highways, can surely provide clean drinking water to its citizens. A nation that can reach the moon can certainly attend to its garbage and provide clean public toilets. Doctors who boast of attracting patients from foreign countries will surely be able to address every one of our public health woes.
In most important health care indicators like nutritional status, maternal and infant mortality, India is near the bottom of the list. We can learn some valuable lessons by seeing how welfare works in other countries. The British National Health Service (NHS) established in 1948 is one of the most successful medical organisations in the world. It is funded by the government and through National Insurance by which a percentage is deducted from the salary of every working citizen. The NHS has a two-tier system of general practitioners and hospital doctors. The GP provides the first-contact care and treats common ailments. Serious cases are referred to hospital. All NHS doctors and staff are salaried. Once they reach a senior position, the job is permanent, with no transfers.
Private practice is allowed at a senior level but it is carefully monitored so as to not allow malpractice or exorbitant fees. The NHS pattern of welfare is followed in Commonwealth countries like Canada, Australia and New Zealand and is an excellent example of socialised welfare. For the last ten years, the NHS has faced problems caused mainly by increasing expenditure. If misuse (like patients seeking emergency service for trivial complaints and the mindless wastage of hospital resources), are left unchecked, its efficiency will be undermined.
In the USA, the health care bill introduced by Obama is set to change things for the better. What I record here is the state of their welfare system until now. Doctors usually opt for specialised, post-graduate training and work in groups that are attached to private hospitals. About 60 per cent of citizens pay a premium towards their medical expenses. Health Maintenance Organisations provide this insurance. Besides doctors, HMOs decide the level of treatment, sometimes even the type of tests and procedures, including surgery. Everything depends on the amount of premium paid. Doctors and insurance companies make a killing out of the deal. This has led to a general hostility towards doctors and increasing medical litigation.
In the USA, the government hospitals which serve the non-insured public are fairly well-run and staffed adequately. The USA government spends $5000 per citizen every year on health. Most of it is spent on their hospitals, treatment of defence personnel and administrative work. Yet, three million hospital beds across the country stay empty and one-sixth of the population has no access to satisfactory treatment. A recent study from Harvard shows that two million Americans are driven to bankruptcy every year by medical bills. In India, too, health costs are the single biggest factor in driving people below the poverty line.
Is socialised medicine relevant in today's world? Non-rich Costa Rica is the envy of many developed countries. The working population pays 15 per cent of its salary towards health care. Every citizen is entitled to free treatment without any distinction between the classes. This is possible because a large number of middle-level health workers are trained to treat simple ailments. Private medical care is available for those who wish to pay but only 30 per cent ever opt for it. Costa Ricans live to 78 years and infant mortality is 11 per 1000, much better than our own. And their expenditure on health per person is one-tenth of the USA's.
Nearer home, Sri Lanka and Bangladesh have better health indicators than we have. Communist and socialist countries like China, the erstwhile USSR and Cuba have done much better than India. In Malaysia, government-funded health care is free and of good quality. Primary health centres called ‘Klinik Desa' give basic health care in remote areas. Their life expectancy is 79 years and infant mortality nine per 1000. (Ironically, with globalisation there is a move to abandon socialised welfare and follow the failed US system!)
Wide gaps
What are our priorities in India? The training of doctors for rural areas and a cheap health insurance scheme will certainly help the poor. But good planning is needed to ensure that these programmes are free of corruption. The advice of professionals experienced in rural and public health is invaluable. We have several internationally acclaimed doctors working in these areas and they have transformed health in hundreds of villages around the country. Why is their example being ignored? We have some very good centres like the National Institute of Mental Health in Bangalore, AIIMS in Delhi and others but the majority of government hospitals have little to commend them.
The health insurance scheme has started well in a few states, particularly Kerala and Gujarat. My own experience with the much talked-about Yashaswini scheme in Karnataka was otherwise. I first heard of it from a well-to-do farmer who had availed of the benefits, because the scheme stipulates that an individual must own a certain area of land to qualify. It had nothing for the landless who are the poorest among rural folk. So while this owner of a farm underwent heart surgery at no expense, his labourer's wife had to pay for surgery on her fractured hip. Rural hospitals registered to treat insured patients complain that they have to overcome a lot of red tape and long delays before being paid by the government.
In Haryana, in a district which was under the insurance scheme, the number of Caesarean sections increased to 50 per cent of all deliveries. Why not, when the insurance cover for a normal delivery is Rs. 3,000 and for a Caesarean, 25,000?
India has come to a turning point. The government is all set to introduce such far-reaching initiatives and it cannot afford to be short-sighted. The corporate health industry is eager to expand its empire. With its powerful influence in government circles, that may happen soon. However, if we genuinely wish to “revolutionise” health, we must turn our attention towards the prevention of disease through public health measures. The only reason for the indifference towards public health is that unlike curative health care, there is no profit in prevention. No wonder our corporate specialists carefully avoid the issue while expanding their curative facilities.
Preventive health care is simple. Take for example the fact that 47 per cent of our children are malnourished (it is 46 per cent for Bangladesh and 37 per cent for Pakistan) and it kills a million every year.
Many NGOs have proposed ways of overcoming the problem. One group in Pune has developed a ‘ Nutribar' costing less than a rupee and made of cereals, groundnut and jaggery. If used as a supplement to food, it will provide essential proteins, iron, vitamins and minerals. The government, or a corporate house with a big heart, could produce and market it. If gutka,shampoo, instant coffee and sugary toffees can sell for a rupee, why not the Nutribar which can put millions of children on the road to health?
We say “Prevention is better than cure” but it remains a platitude. If the government, the medical professionals, and the corporate health industry could enlarge their tunnel vision, we may, one day, pride ourselves in being a healthy nation. Merely pumping in money will not transform health. What it takes is empathy, imagination and common sense.
Kavery Nambisan is a surgeon and novelist based in Lonavla.
