India has an abysmally low percentage of people with access to decent health care. About 300 million Indian citizens live below the poverty line and, for them, medicine is prohibitively expensive. For decades, serious medical conditions have pushed families into poverty and destitution. From 2000 to 2015, the annual national health-care expenditure averaged around 4.00% of GDP; the Indian government spent only around 1% of GDP, with families largely chipping in with the remaining 3.00%.
In 2018, the government launched Ayushman Bharat, a health insurance scheme for the bottom 40% of India’s population. Access remains patchy. Furthermore, health-care infrastructure remains pitiable, acute poverty persists and so does lack of education or awareness. This leaves millions vulnerable to exploitation or neglect, or both. A 2018 study by The Lancet found that 2.4 million Indians die of treatable conditions every year. Of the 136 nations examined in this study, India was in the worst situation.
In this guest edition of The Interview, Nilanjana Sen talks to Dr. I.P. Singh, a senior consultant in plastic and reconstructive surgery at the Indraprastha Apollo Hospitals, New Delhi, about the state of the health-care system in India, the role of the private sector and the challenges faced by professionals in the field.
This interview was conducted prior to the outbreak of the COVID-19 pandemic.
Nilanjana Sen: Is corruption a big issue in India’s health-care system?
I.P. Singh: Corruption has been all pervasive in every sector and every walk of life right from the early 1960s. Unfortunately, it has spread to the health-care sector as well. In health care, corruption takes myriad forms such as unnecessary procedures, overcharging for necessary procedures and not providing treatment or services that have already been paid for. The mentality that pervades the environment outside the medical profession has finally seeped into health care too, and it is not possible to insulate the profession from the outside environment.
Quacks and unqualified practitioners abound and comprise between 57% to 58% of India’s so-called doctors. I remember a case from some time ago when some quack claimed that he had removed a dead serpent from the abdomen of a lady. He probably removed a necrose intestine and claimed to have found a snake. In another famous case, a doctor in Assam claimed to have transplanted a pig’s heart into a male patient. This doctor wanted to be recognized for his achievement even though the patient died.
Doctors and quacks also prescribe fake or substandard drugs in remote areas. We have to realize that 70% of our population lives in far-flung rural areas, and it is very difficult to monitor what happens there. Most people are barely literate, so a lot of unethical practices go unnoticed and unchecked. Corruption is now endemic in India’s health-care system.
Sen: In such an unequal country, what is the real state of health-care coverage? Can the new government-backed insurance system be a success?
Singh: There are two main reasons for poor health-care coverage. First, we don’t have enough trained medical personnel. The World Health Organization recommends a ratio of 1:1,000, i.e., we should have one doctor for every thousand persons. For India, the doctor-population ratio statistic is unclear and murky. We do not know whether we have one doctor for 1,700, 1,500 or 1,000 persons. We lack clarity because we do not know how many doctors are registered medical practitioners, how many practitioners are still active, how many are out of practice and how many are quacks. The government admits that more than 75% of the primary health-care system is managed by people who are not qualified to practice medicine. This is one of the major reasons for poor health care in India.
Second, most of the trained medical personnel are not willing to serve in rural areas, which lack basic facilities and infrastructure such as electricity and roads. Even though basic amenities have improved in recent years, working at rural medical centers is often demoralizing. There is rampant pilfering of drugs, malfunctioning equipment and terrible waste management. Further, there is a lack of professional development opportunities, poor management and a lack of transparency at all levels.
The new insurance backed system of Ayushman Bharat is a very good idea to start with, but I hope that the people who have planned it have done their math correctly. It is an extremely difficult and arduous task to plan health care for roughly 500 million people. If you look at health care across the world, uniform and fairly good health coverage is limited to Britain, France, Germany, Austria, Norway, Sweden, Switzerland and some other countries in Europe.
Health care is fairly decent for most people in the US, but the American health-care system has its share of major flaws. Approximately 33% of the American population does not have adequate medical insurance and is left at the mercy of God. Many more Indians find themselves in a similar situation. India’s large population means that the government has to provide health care at scale and, therefore, must get its mathematics right for the program to be successful.
Ayushman Bharat must not only sort out finance but also build a team of dedicated staff. Only then can they plug gaps and leakages in the system. Last year, I was reading the newspaper and was shocked to learn that 338 hospitals were practicing fraud. Of these, the government barred 97 hospitals from its insurance scheme. This year, it barred another 171 hospitals. Such fraud will derail Ayushman Bharat.
Sen: The present government seeks to involve the private sector in the health-care system. Will this help improve accountability and reduce malpractices?
Singh: The intention behind this idea is good, but one man or one agency with good intentions cannot set everything right. There has to be a tectonic cultural shift. Many unscrupulous people will claim benefits at the cost of voiceless people who will lose out. There will be cases of wrong billings, overcharging or charges for investigations that are simply not done. So, auditing the system and holding fraudsters accountable is crucial. However, I am not sure the government would be able to find so many auditors or be able to prosecute most fraudsters. Besides, there is an acute lack of basic infrastructure.
Sen: What exactly is this lack of infrastructure you are referring to?
Singh: As I mentioned earlier, there is an acute shortage of medical facilities in the rural areas. Having said that, we must remember that health-care infrastructure doesn’t mean medical facilities such as a hospital or a primary health center alone. It also includes good training institutions, laboratories and research facilities.
There are hardly any such facilities in this country except for the Central Drug Research Institute in Lucknow, the Centre for Cellular and Molecular Biology in Hyderabad, the All India Institute of Medical Sciences and a handful of other places. Even existing facilities lack funds for research, which is dominated by foreign pharmaceutical firms who have the money to invest in research. They market, advertise and sell their drugs, equipment and medical devices at astronomical prices to make large profits. Sometimes, these drugs are hyped up and private hospitals become willing partners in prescribing them because they get a share of the profit.
One drug called Xigris was used for septicemia. A single dose of Xigris cost more than $8,000, and I know of no patient who survived after being given this drug. Later, Eli Lilly withdrew this drug from the market. Big pharmaceutical companies often sell such drugs in developing countries like India to make a killing.
Sen: Are you saying big pharmaceutical companies are taking advantage of patients?
Singh: Yes, big pharmaceutical companies spend huge sums on advertisements and rope in doctors through various inducements. Take the case of knee and hip implants in India. Many implants, which were stopped in developed countries a good two or three decades ago, were being used in India until very recently. If this is not taking advantage of patients in poor countries, I don’t know what else is.
Sen: If there are so many malpractices by big pharmaceutical companies, what can the government do to control them?
Singh: It is very difficult to exercise control over these companies because most of them are multinational. They do not lie under India’s jurisdiction. Furthermore, India depends on other countries for active pharmaceutical ingredients. In fact, 66.69% come from China alone.
Foreign players are not prepared to negotiate with the government on price. The drug controller of India has tried to control prices of some drugs such as antibiotics, anti-tuberculosis medicines and antimalarial tablets, but this has led companies to stop production of many life-saving drugs when their profit margins have gone down.
Sen: Is that not sheer blackmail and profiteering?
Singh: Yes, it is. Once the companies stop production, there are shortages and panic often grips the market. People start to hoard essential medicines and sell them in the black market. Once the trade goes underground, prices become very difficult to control, further aggravating the original problem. So, companies know that they have bargaining power over the government.
Sen: What are the other issues facing Indian health care?
Singh: Medical education has declined precipitously. When I studied at King George’s Medical College, my professors were extraordinary. Today, medical colleges are run by politicians, bureaucrats and property dealers along with corporate houses. It is bizarre that people who ran sweet shops or dairy farms have suddenly started medical colleges. Many students who graduate from such institutions are doctors only in name and are really little better than quacks.
The Medical Council of India is deeply compromised. Ketan Desai, one of its past presidents, was found guilty of corruption. He was convicted of taking bribes to approve shady institutions as recognized medical colleges. With the fox guarding the henhouse, it is no surprise that regulation is utterly ineffective in safeguarding the interests of citizens.
There is another major issue. During British rule, the Indian Medical Service (IMS) and state medical services provided the backbone of health care to a limited population. After independence, the Indian Administrative Service (IAS) and the Indian Police Service continued, but the IMS was discontinued. Health care was now the responsibility of the states, but they were not given taxation powers to fund it.
India never planned its health-care system properly. Politicians and IAS officers had no domain expertise. Doctors, nurses and medical professionals were cut out of policymaking. Unsurprisingly, India’s health-care system is in shambles.
The views expressed in this article are the author’s own and do not necessarily reflect Fair Observer’s editorial policy.