Dr Sedevi Angami
[dropcap]E[/dropcap]VER since Manmohan Singh came into the scene and opened India to the world market, health care in the country has changed dramatically. The best health technology in the world has become accessible to the Indian who can afford it. PET scans, Gamma knife, Robotic surgery, designer drugs for cancer, capsule endoscopy, state of the art Radiotherapy machines etc have all come to India, so much so that Indians no more need to go abroad for treatment. Corporate hospitals have changed the face of health care delivery. The 400 million middle class of India with its greatly increased earning and purchasing capacity has fueled this growth in health care. Insurance has come in a big way to further the cause.
Health tourism has become very popular whereby a foreigner who cannot afford insurance in his home country comes to India, gets treated with 5 star facilities in the best hospitals in India, sees the Taj Mahal, Jaipur forts and flies back home – all in a neatly arranged package. What is dirt cheap for this foreigner is a fortune and out of reach for most local Indians. With the rupee falling, this will increase. NRI doctors are returning to India because they earn better in India and can still look after their old parents who refuse to migrate to the States.
Corporate hospitals have swallowed the best Doctors from medical colleges and created an internal brain drain. Doctors now jump from hospital to hospital and sell their souls to the highest bidder. Those who earlier earned in the thousands now suddenly earn several lakhs up to Rs 3 crores per month. Corporate hospitals are now listed in the stock market and pay dividends to their stakeholders. Smart young MBAs call the shots. They also give targets to doctors to fulfill. Doctors asking for labs to give false, inflated test results have become common place. They then use these false results to tell the patient that they need a surgery or ICU care. A normal delivery in some corporate hospitals can cost as much as Rs 65,000/per day. The same would cost Rs 2000 to 6000 elsewhere. Since the metros pay so much, most doctors would flee from the rural areas thereby depriving the rural poor of the best brains to care for them. Some towns in Andhra Pradesh have whole streets full of private clinics each selling their wares like a mela.
The powerful corporates also influence the lawmakers in the country to pass health care establishment bills that can choke and destroy smaller hospitals. Introduction of quality checks and accreditations – largely encouraged by the corporates has improved the quality of health care. This of course comes with a cost.
Commissions are paid to the doctors who order a lot of investigations. If a doctor refers a patient to another center, that center gives him a commission. This causes a lot of unnecessary investigations. Since the patient cannot trust the doctor anymore, they are forced to seek a second or third opinion, thereby increasing their spending and delaying appropriate treatment. Litigation has also greatly increased since patients no more trust their caregivers and many doctors use the patient as a milking cow to satisfy their greed. Today both the doctors and their patients are suspicious of each other. Very often, partially informed public who have access to the internet harass even well meaning good, sincere doctors and ask for first world quality of care to health care professionals who have third world support systems. This causes angry doctors to go on the defensive and do more costly investigations for fear of being sued by unreasonable patients. It is a vicious circle that increases cost and nobody wins in the process.
Medical colleges have also mushroomed and make good money. Some of the private medical colleges charge Rs 50 lakhs for an MBBS seat. A seat for a 3 year post graduate course in Pediatrics now costs Rs 75 lakhs and Radiology goes for Rs 1.5 crores. Dermatology and Radiology which were earlier the last options for post graduation are now center stage and have become the most expensive and sought after subjects since the entry of Cosmetology and interventional radiology.
After having spent so much on their education, it is natural for many of these doctors to want to recover that money quickly. The ROI or Return on investment is now the buzz word.
In earlier times fresh MBBS doctors never asked how much they would be paid on joining a new hospital. They were happy getting the experience. Today, that is the first question many young doctors ask on seeking a job. Doctors in India are not taught anything about communications or ethics. As a result when they do wrong, they are just reflecting the society they come from. The MCI is contemplating introduction of bioethics into the MBBS curriculum. Finding faculty and creating a curriculum for this will not be easy.
Realizing the need for more health care professionals in the rural areas, the Central Government introduced the National rural health mission.
The NRHM has created a huge amount of new jobs along with almost unlimited funds and infrastructure. It also created certain accountability structures for the utilization of this money. It has partially succeeded in its initiative. This however comes with tremendous waste of resources in places where monitoring is poor or the leadership is lacking. Some states have used this programme to very good use.
The cost of health care in the country has greatly increased. Health insurance like RSBY and other schemes have helped lessen the burden for the common man. RSBY gives you up to Rs 30,000 for an in patient admission for a family of 5 per year. Rich states like Tamil Nadu give up to lakhs as health insurance for their citizens. Good states like Mizoram have credit facility in places like CMC Vellore whereby, their government servants can have a Kidney transplant free of cost.
Hospital admission is the single most important reason why people go under the poverty line today in India ( World bank study). In our hospital at CIHSR which is a very low cost hospital, a rough study showed that 70% of patients admitted to the General ward took loans to get admitted for a period of 2-3 days. Loans in Nagaland come with an interest rate of 10-20% per month. Once you get into the money lenders hands, you land up in a spiral of debt for years to come.
The 6th Revision of pay has been a windfall for the Government salaried class. These have experienced a sudden jump in their earnings and therefore their spending. Globalization has opened the economy and the private sector earnings have also jumped. A large chunk of the rural and urban poor have been left untouched by these happenings. Pricing in Health care is aimed towards the middle class. This has greatly increased the gap between the rich/ middle class and the poor. This is a dangerous trend and explosive raw material for crime, neglect of the poor and a new revolution.
What are the options for effective reasonably priced ethical medical care today? The current trends cause a lot of anxiety. One has to choose from Government hospitals, private clinics, mission hospitals, medical colleges and corporate hospitals. Each have their pros and cons.
There is a need for Community owned but professionally run centers.
1. These require funding and subsidies from the Government for keeping the cost low.
2. They also need autonomy of function to keep them efficient.
3. These centers must be linked to teaching medical colleges in order to keep them up to date.
4. They need good interaction with civil society to keep them relevant.
5. They need appropriate mechanisms to keep them highly accountable, ethical and transparent.
6. They must be innovative and progressive to make the best use of resources and manpower.
7. They must interact actively and be supported by Government departments in order to be in touch with mainline national programmes.
8. They need to have accreditation with quality council of India to maintain a high level of quality.
A network of such centers all over the country would impact the health of the country in a more cost effective manner and not burden the already over taxed population.
They would cost the taxpayer a fraction of the amount spent on present day health bills.
The alternative is to continue with the status quo and see health care delivery degenerate further as human greed and wickedness increases incrementally as the days go by.
