In the absence of a robust state-funded health infrastructure providing free care, citizens have no option but to seek out private facilities. As a result, we have a burgeoning private healthcare sector, unregulated and often exploitative
A single episode of major illness is enough to eat away the life-savings of most individuals in India . In fact, there is data to suggest that such illnesses push several families below the poverty line. The World Bank reported in 2002 that irrespective of income class, one episode of hospitalisation is estimated to account for 58% of per capita annual expenditure, pushing 2.2% of the population below the poverty line. Even more disconcerting is the fact that 40% of those hospitalised had to borrow money or sell off assets. During 1986-96, the number of people who could not access healthcare because of financial reasons doubled over the baseline.
This obviously suggests a greater role for the public sector in healthcare. Yet, several studies have recorded the growing role of the private sector in the provision of healthcare in India . In a study of World Bank projects operating in India , Kamran Abbasi makes it clear that lack of funding in the public healthcare sector translates into inadequate quality of service, which forces "the poor to turn towards the private sector, which in turn exploits clients by using expensive inappropriate technologies and overprescribing".
Writing on the role of private practitioners in tuberculosis control, Mukund Uplekar et al note in The Lancet that 80% of households prefer to use private sector treatment in India for minor illnesses, and 75% of households prefer to go to the private sector for major illnesses. An examination of healthcare access patterns for the population leads to the startling revelation that the vast majority of people have been forced to rely on private facilities because there is an absence of state-funded alternatives.
According to figures from the National Sample Survey Organisation for 1998, quoted in a study by V R Muraleedharan and Sunil Nandraj, there was a 7% increase in the number of outpatients patronising rural private sector facilities, from 74% in 1986-87 to 81% in 1995-96. In urban areas, this rise was about 8%, from 72% to 80% during the same period. In the case of in-patients, the rise was sharper, from 40% to 56% in the case of rural and 40% to 57% in urban areas.
A snapshot of the private healthcare sector in India emerging from the study by Muraleedharan and Nandraj shows that in absolute terms, the size of the health infrastructure is significant, but its distribution is lopsided and urban-centric. There is one qualified doctor for 802 people and one hospital for 11,744 people, besides one bed for 693 people. But there are serious imbalances in the distribution of these facilities. In Tamil Nadu, at least 70% of 37,733 allopathic physicians are in the private sector while 10,000 are in government service. There are nearly 10,000 doctors in and around Chennai. Therefore, the ratio of doctors to population changes from 1:800 for Chennai to 1:1,590 for the state average.
The National Council for Applied Economic Research reported in 1992 that a study of household surveys showed over 55% of illness episodes being cared for by private facilities, and 33% to 39% by the public sector. PHCs and sub-centres catered to only 8.2% of cases in rural areas.
Why do so many patients seek private doctors?
In some settings, private practitioners are perceived as providing better care because they include injections as part of every treatment, and are willing to make house visits, which are convenient. In contrast, government services are not popular because of long waiting periods, the arrogant attitude of staff and non-availability of medicines.
In the absence of a robust state-funded health infrastructure providing free care, citizens must seek out private facilities. Based on a study of the weaknesses in the tuberculosis control programme, The Lancet reported that among 22 countries with the highest prevalence of TB, private health expenditure as a percentage of the total was among the highest in India , at 87%. The number of patients incurring 'out-of-pocket' expenditure as a percentage of total spending was also unconscionably high at 84.6%.
Acknowledging the rise in patronage of private healthcare in many poor nations, the British Medical Journal traced the phenomenon to greater flexibility of access, shorter waiting time, greater confidentiality, and sensitivity to user needs. However, there cannot be an unreserved commendation of any measure to expand the private sphere without an overarching concern for a state-funded care system. The debate on the debilitating impact of a policy that is guided by private care imperatives has dominated proposals to revamp the National Health Service (NHS) in the United Kingdom , with suggestions that the discourse on expansion is actually driven by a desire to pave the way for the entry of private care providers from the United States and elsewhere. Thus, tax funds would indirectly lead to an expansion of the private healthcare sector at the cost of the public system.
This issue is of particular concern to India , as the private sector has not met its obligations of providing free care to a particular percentage of poor patients as required by law. Citing this little-known and poorly-enforced provision, Members of Parliament Ram Kripal Yadav and Daroga Prasad Saroj wanted to know, in the Lok Sabha, the steps taken by the Centre to ensure that private hospitals provide 30% of their patients free treatment. Union Minister of State for Health and Family Welfare Panabaka Lakshmi replied on July 21, 2004 : "Health being a state subject, it is for the respective state governments to formulate conditions and norms for setting up of private hospitals... (and) with regard to the treatment of poor patients and also to ensure that the conditions and norms are followed by private hospitals."
The issue becomes clearer in the answer of Health Minister A R Antulay to a question in the Rajya Sabha in 1995. The minister said: "The 4th Joint Conference of Council of Health and Family Welfare held in October 1995 also recommended that the private sector which benefits from concessions should provide a minimum of 30% beds and 40% outpatient/diagnostic services free for treatment of the poor. In the past, private hospitals/nursing homes were allowed to import medical equipment at concessional rates of duty subject to the condition that a certain percentage of free treatment would be provided in OPD/IPD to poor patients. The state governments are required to check whether these conditions are being met by private hospitals/nursing homes."
Regulation and the lack of it
There is a complex set of factors that have rendered regulation of medical care practically meaningless in India . Muraleedharan and Nandraj report that the major problems include lack of monitoring by statutory bodies, outdated and inadequate legislation, and inability of the government to enforce even the available regulatory laws.
One of the earliest laws in force is the Delhi Nursing Homes Registration Act 1953, which requires that all private nursing homes satisfy a set of criteria and register themselves. However, a survey reported in 1994 found that there were 1,600 unregistered nursing homes functioning in the national capital, despite the law, indicating that it was not being enforced even in the city where national laws are made.
On the question of costs associated with private care, V R Muraleedharan points out that there is inadequate information on in-patient care to come up with a sound analysis on whether the costs are justified. The lack of sustained data collection was confirmed by the then minister of state for health and family welfare, in answer to a question in Parliament: "Health being a state subject, the details of hospitals run by state governments in the country are not maintained centrally."
There is thus considerable evidence to conclude that the poor are unable to access quality healthcare in India due to inequities prevailing in the system. Health insurance, either taken individually or provided as group cover, is helping some sections, though this remains a minority phenomenon in the overall scheme. The imperatives for policy therefore are to bring about greater budgetary expenditure on public health, institute monitoring mechanisms involving transparent and professionally audited procedures both in the public and private sectors, and ensure that the private sector, which has a legal commitment to share its facilities with the poor, is compelled to do so.