Only the economic elite in India can afford effective health care. The Indian Express recently ran a series on the capital's major hospitals, including the All-India Institute of Medical Sciences. Everywhere it was the same story: facilities strained far beyond capacity, doctors stressed by unendurable workload, virtually non-existent support by way of services, equipment and supplies. Yet every inch of space was crammed with people desperately needing treatment.
Anyone who has tended to a sick relative or friend knows that costs of medicines, care and procedures have relentlessly risen in private institutions, where we go perforce due to the utter inadequacy of what pass for public facilities. So some data may be a bit of surprise:
According to an article in Mint (August 6, 2015), hospitalisation expenses (a good proxy for overall health care) almost exactly kept pace with general inflation in India between 2004 and 2014, rising at a compounded annual growth rate of just over 10 per cent. For seven years (2007-2014) during this period, Indian inflation was very high. Thus, despite rising costs, the share of hospitalisation in family budgets remained stable. Households are generally not in a position to increase proportions of any major items of expenditure without jeopardising their overall welfare. The stable pattern is thus a manifestation of a low-level, basically unattractive equilibrium between limited means and an ever-expensive service, health care.
That in turn raises an important and disturbing question: is this satisfactory for a society that professes to prize people's welfare above all else?
The answer to this rhetorical question will lead to the unrealistic and unattainable solution that public expenditure on health must rise manifold from the present abysmally low level of 1.5 per cent of the GDP. Even the most resolute political will cannot make this happen. And if that somehow materialises in the long run, would but be a partial solution.
Let us start with medicines. Most drugs for even not very uncommon ailments are priced way above the purchasing power of all but the most affluent. A case of a civil servant spending over Rs 70 lakh for his hepatitis C treatment with sofosbuvir was recently reported, forcing him to incur many loans. And that was not treating the elderly with terminal conditions. The irony is that many practitioners are aware of cheaper substitutes which cost a tiny fraction for the treatment. Doctors abroad are reportedly averse to prescribing these, despite their effectiveness, and our doctors are happy to follow the lead.
Even far simpler medicines become more expensive through simple tricks. A common, affordable formulation of loratadine, an anti-allergenic which does not induce drowsiness, was discontinued in favour of another which cost two-and-a-half times as much. No one prescribes simple Avil, which costs 25 paise a pill and works well through the night, when Allegra is available at Rs 5 a pill to do the same job. The lowly paracetemol now comes dressed up in time-release formulations, at, you guessed it, far higher prices and the low-cost simple pills disappear from chemists' shelves. I can count dozens of medicines myself which have undergone such fancier reincarnations over the last decade or so. I have also discovered that most branded drugs prescribed by doctors have cheaper substitutes with the same formulation and equal effectiveness.
Many champions of the pharmaceutical industry cry wolf when price controls are suggested to stop what is tantamount to gouging. They forget that Drs Anji Reddy, Parminder Singh and Yusuf Hamied provided generics for many diseases including AIDS, which saved numerous poor lives and brought eternal glory to these pioneers.
This is also true of medical procedures, simple and complex. A friend in Mumbai with cataract was told that phacoemulsification and lens implant would cost Rs 90,000 per eye. The exact same procedure costs a third as much in Vadodara. Dr Devi Shetty of Narayana Hrudayalaya has been advocating tirelessly the case for near-assembly line procedures for heart ailments which slash costs and become more affordable for a much larger population. He has successfully demonstrated the practicality of his approach. But the boom in corporate hospitals merrily takes the turnpike to high cost care.
That celebrated advocate of compassionate care, Dr Atul Gawande, asked the most relevant question ("Big Med", The New Yorker, August 13, 2012): “In medicine, good ideas still take an appallingly long time to trickle down. …Scaling good ideas has been one of our deepest problems in medicine…[I]nsurance-company reviewers did hardly any better. We’ve been stuck. But do we have to be?”
The writer taught at Indian Institute of Management, Ahmedabad, and helped set up Institute of Rural Management, Anand