Governance

Chronic ailments plague India’s health sector

Greed for profits is one of the biggest problems that affects India’s health sector, where the common person and poor are left at the mercy of rent-seeking private sector and big pharma Arun Kumar
Enter Vol.

“All is well,” might be a catchy line from the superhit film, 3-Idiots, but that cannot be said about India’s health sector. India’s health sector is creaking. This brutal truth has been known among experts for a long time now, but it became starkly visible during the Covid-19 pandemic. Ask questions and you will be swamped with statistics from govt sources:  trends in IMR, MMR, life expectancy, number of doctors per thousand people, budget allocations, access to doctors and hospitals etc. However, without context, these are just statistics, mere numbers. The problems staring in the face of India’s health sector are related to physical infrastructure like hospitals and dispensaries, and medicines.

According to a 2016 report in the Economic Times, 80 percent doctors, 75 percent dispensaries and 60 percent hospitals are in urban areas, serving a mere 28 percent of population. Only 37 percent of rural and suburban population have access to medical care.  But does having access translates into medical help?  Imagine starred hotels lined up in the cities; they are accessible, but can the common person avail their offerings?  The revealing truth is that shorn of options, even the poor are constrained to approach private hospitals because the number of patients for every govt doctor is humongous forcing them to wait for several hours.

Loss of wages and doubt about doctor being able to pay adequate attention, force the patients to private practitioners. Govt doctors are generally good, but their approaches differ greatly. Some are good listeners and sympathetic, while others do not devote much time to each patient. Since multi-speciality govt hospitals are located only in major towns and cities, they are swamped by patients from neighbouring regions, where facilities are non-existent. This lopsided health infrastructure allows quacks to walk into these spaces. Dependence on quacks is a common phenomenon in rural as well as poorer urban areas.

Hospitals and hospitality

Unbridled proliferation of corporate hospitals has further muddied the waters. Suffice to say that they have made fleecing into a fine art form at the cost of the unfortunate people who are forced to seek health care in such places. It starts with paying astronomical capitation fees to get an admission in medical colleges. Clearly those paying it are treating it as investment, and their major concern is to get returns on investments, leading to jobs in or setting up high-end corporate hospitals. Invariably are built on government lands on the condition that such private hospitals will offer free treatment to the poor, but, this condition is hardly implemented. Therefore, access is therefore a myth.

Another area of concern is the stranglehold of pharmaceutical companies on the system that extends to medical devices like implants. Rent seeking through unnecessary tests and avoidable procedures put great strain on patients. This is more rampant in the case of private hospitals and practitioners, but   govt doctors too are not immune to the practice.

Corporate hospitals are essentially companies for profit. For the proprietors of such hospitals, it is easy to cultivate powerful friends. Concern for human suffering and compassion is posited against maximising their revenues. The practice of levying differential charges from patients in general ward, private and semi-private rooms is hardly ethical. More “serious” the ailment, greater the opportunities for earning higher profits. Cancer is only one such ailment.

A look at the number of procedures and diagnostic tests carried out on CPU-backed patients vis-a-vis other private individuals under treatment is revealing. Even the percentage of unnecessary C-sections performed in govt hospitals is much lower than in private hospitals. Similarly, a look at the number of other surgeries carried out in private hospitals in comparison to government establishments gives a fair indication of the real motivations of private health sector. The conditions imposed for getting NABH accreditation are supposed to ensure quality service for all patients. However, in practice these conditions remain on paper. Getting empanelled by PSUs serves as good publicity for the private hospitals. Whether they abide by the NABH credo is a moot point.

To be meaningful healthcare should conform to some basic norms. The first level of medical care should be reachable within an hour. Primary and sub-primary Health Centres are supposed to carry out this function. But the reality is very different. Most of these centres are ill equipped and woefully understaffed with doctors. In rural India, doctors and health care workers go missing from their stations for days.

Pharmaceuticals

Modern medicines have revolutionised health care. They have played a vital role in the spread of diseases and improved life expectancy. The pharmaceutical industry (allopathic drugs) gained ascendancy in India in just over 150 years. Available literature tells us that vaidyas, hakims and   physicians were researching, discovering herbs, and preparing concoctions to treat ailments since ancient times. Most of these systems are still in vogue, but allopathic medicines have contributed immensely through a variety of life-saving drugs, diagnostic tools, surgical procedures and use of life-saving devices, among others. Vaccination against deadly diseases like smallpox, polio, whooping cough etc., has saved millions from these scourges. Dentistry has its own niche.

On the flip side, broad-spectrum antibiotics get prescribed indiscriminately, often causing undesirable side effects. No wonder they are among the highest-selling group of drugs. Similarly, anti-histaminic and analgesic drugs have created a pill popping generation. The global pharmaceuticals industry tops 1.3 trillion dollars annually.

In the case of branded drugs, taking shelter under Trade Related Intellectual Property Rights (TRIP), which permits the discoverer of a drug to patent them for 20 years, enables premium or higher pricing. It bars others from producing the drug, except under licence from the patent holder. Substantial difference between the prices of branded and generic drugs, having identical active ingredients, corroborates the charge. Pharmaceutical companies argue that they spend millions of dollars in the discovery, development, and multi-stage trials of a new molecule before the drug administration approves its sale. They need to recover these expenses while the patent lasts. This argument is specious since the sales don’t stop with expiry of patent. It also incentivises efforts for evergreening of patents.

India introduced a system of fixing prices of notified drugs in any dosage form to make them more affordable. Initially, all drugs were placed under price control in 1979. Changes were made over the years and the today that number stands at around 384, including medical devices such as stents. A formula was devised to ensure adequate profit margins for the manufacturers as well as the pharmacies. It was nevertheless not so satisfactory, as the list of notified drugs left out many important medicines where margins were usurious. 

Pharma companies are allergic to price control. Over time, this process has been simplified fixing price, ensuring fair returns for the companies and margins for pharmacists. It also provides for self-regulation mechanism, but companies keep trying to bypass the covenant to charge higher prices.

The American Pharmaceutical Manufacturer’s Association (PhRMA) describes its motto as: treat today, cure tomorrow and prevent day after tomorrow. This statement, however, can be interpreted in more ways than one. In one way, it is an admission that treatment is not synonymous with cure. Possibly the first line is symptomatic relief, but it does raise several questions. One such may be on safety of drugs approved for sale. The side effects of the drugs become apparent after many years and dozens of drugs have been banned or withdrawn later after years of being administered. Pharma companies try to market new products at the earliest despite known side effect, usually noted in fine print. In all fairness, they must unequivocally explain the likely collaterals to the physicians concerned, who in turn are duty bound to caution and guide the patient.

Pharma companies promote geriatric medicine, underlying their motive of utilising the opportunity for enhanced need for medication of elderly with prolonged life expectancy, thanks in good measure to modern medicine. Hardly any thought is spared for research and production of drugs for endemic disease, most of them afflicting the poor, ostensibly because most are too poor to afford them. Sales must depend on government’s largesse, which does not seem to be happening anytime soon.

India, while comparatively quick to introduce a new drug, does not act with same alacrity in following suit with respect to drugs that are banned or withdrawn elsewhere, which continue to be sold in the market with impunity for a long time. Influencing doctors through the technique of holding conferences in resorts at exotic locations, all expenses paid for and expensive gifts are not unknown. Certain lifestyle diseases such as diabetes, cholesterol and cardiovascular conditions have been used as a platform for widening client base. Safe limits of blood sugar, BP, LDL etc were reworked to induce larger numbers to start medication.

The medical profession considered as noble is increasingly seen like any other business, with exceptions of course.  The Hippocratic oath is intended to imbue a sense of propriety and responsibility in doctors to use their knowledge to treat and cure the patient efficiently and not take undue advantage their ailment. Even the name may not ring a bell for many, since it is administered en masse with a loud “we do” from and has become mere ritual today.  

( The writer is a former IAS officer)

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