March 27, 2006

In Poor Health

Doctors bear the brunt of collapsing system
The media has been covering a spate of recent attacks on doctors by disgruntled patients. More recently, this has led to a strike by doctors in Maharashtra, calling attention to their working conditions. A section of observers seems to feel that doctors, for their arrogant and heartless behaviour, deserve what they get. Others have argued that given the appalling working conditions — not enough people, not enough money, not enough drugs or equipment — doctors can hardly be expected to perform miracles. While the debate is legitimate, what is ignored is the systemic failure staring us in our faces.
There has been a sharp decline in the state's commitment to public health over the last 15 years. As a percentage of gross domestic product, India’s public health expenditure is the fifth lowest in the world. As the National Health Policy (NHP) admits, this is, at 0.9 per cent of the GDP, lower than the average even in sub-Saharan Africa. Along with cutbacks in state spending on health, policy measures have encouraged the growth of the private sector in healthcare. We have the largest and least regulated private healthcare industry in the world.
The policy of levying of user fees has impacted negatively upon access to public health facilities. With the sharp rise in healthcare costs, as the NHP acknowledges, medical expenditure has emerged as one of the leading causes of indebtedness.
Half our rural population has food intakes below that of the countries of sub-Saharan Africa. The rate of decline in IMR, which was significant in the 1970s and 80s, decelerated remarkably in the 1990s. The percentage decline in IMR between 1971-81 was 14.7; between 1981-91 it was even more marked at 27.3 per cent. However, in the period 1991-99, there has been a marked stagnation, with the rate of decline in IMR a mere 10 per cent. Similarly, the pace of decline in the under five mortality rate has come down.
Decline in public investments was matched with growing subsidies to the private sector. Concurrently, marked shifts have occurred in healthcare utilisation. Among people who sought out-patient services in 1995-96, more than 80 per cent did so in the private sector, a sharp increase in even the poorer states.
In 1995-96, 55 per cent and 57 per cent in rural and urban areas respectively were hospitalised in the private sector compared to 40 per cent in 1986-87. NSS data indicates greater inequality in use of health facilities in both rural and urban areas in the mid-90s compared to mid-80s. In urban areas, inequality in use of public facilities did not worsen significantly, but inequality in use of private facilities did. In rural areas, inequality in in-patient use of public hospitals increased over this period. The steep fall in rural hospitalisation rates, along with increasing use by the better-off, indicates that the poor are being squeezed out. World Bank policies on health succeeded in doing exactly the opposite of what was ostensibly its raison d’etre — reduce utilisation of public services by the better-off to increase access to the poor.
Costs of both out-patient and in-patient care increased sharply in both rural and urban areas, compared to the mid-80s. Private out-patient costs increased by 142 per cent, against 77 per cent in the public sector in the rural areas. In urban areas, private outpatient costs increased by 150 per cent compared to 124 per cent in the public sector. The increase in costs in in-patient care is even more striking: Average costs rose by 436 per cent in rural and 320 per cent in urban areas. At the same time, the proportion of people not availing any type of medical care due to financial reasons increased between 1986-87 and 1995-96 — from 10 to 21 per cent in urban areas, and from 15 to 24 per cent in rural areas.
The prevailing pattern of illness cannot be fundamentally altered by a doctor-dependent healthcare system. Yet what has occurred is the production of unemployed doctors, while the number of para-medical workers is woefully inadequate. The number of medical colleges has increased, producing about 16,000 medical graduates every year. These professionals are unwilling or unable to work in rural areas, where despite high maternal mortality, over 40 per cent of pregnant women receive no ante-natal care, and only 16 per cent of women obtain institutional delivery. As many as 59 per cent of doctors and 85 per cent of hospital beds are concentrated in urban areas, which cover just over 25 per cent of the population.
Given the collapse of the healthcare system, it is not surprising that irate patients take out their grievances on doctors. But the private sector is no better. This calls for fundamentally rethinking neo-liberal shibboleths. In Sri Lanka, about 97 per cent of inpatient care and 83 per cent of out-patient care is in the public sector. We don’t hear stories of doctors getting beaten up regularly either.
The writer is professor, Centre for Community Health and Social Medicine, JNU.

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