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Focused Efforts From Govt. And Civil Society Will Reduce India’s High Healthcare Expenses

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UHC logoEditor’s Note: This post is a part of #HealthForAll, a campaign by WHO and Youth Ki Awaaz to advocate access to healthcare for everyone, everywhere. If you have ideas on how India ensure access to quality and affordable healthcare for all by 2030, share your opinion.

“My husband died of cancer this month. We did our best to treat him. But, we could only manage a loan of Rs 80,000 from the local moneylender. It wasn’t enough to keep him alive,” shared 32-year-old Geeta Devi of Bhitaura district of Fatehpur, Uttar Pradesh.

“We never had an easy life, but now with my husband gone it’s a very difficult time for the family. The responsibility to raise our children and repay the loan is on me,” she said, in a heavy voice trying hard not to break down.

Geeta Devi and her husband, Arjun Nishaad, were brick-kilns workers in Fatehpur district of India’s most-populated state. With the seasonal employment at brick-kilns not enough to run the family, Arjun used to make additional earnings as a helmsman ferrying passengers and an agricultural labor. Two years ago, Arjun fell severely ill. His condition started deteriorating rapidly. His family took him to the local ‘doctor’ – a quack – the only treatment they had access to.

All hell broke loose when Arjun was taken to a qualified doctor in Fathepur city where he was diagnosed with cancer. Unable to meet the extremely high healthcare expenses, Arjun, 35, passed away leaving behind his wife Gita with five children (four daughters and a son).

Geeta Devi and her family represent 63 million Indians, who are pushed into poverty by catastrophic healthcare expenses every year. According to recent studies by The Lancet, a British Medical Journal, Indians were the sixth biggest out-of-pocket health spenders in the low-middle income group of 50 nations in 2014.

Medical experts, researchers, and the patients, that Youth Ki Awaaz talked to, have attributed this to:

a.) The state of district-level Primary Healthcare Centers(PHCs),
b.) Underfunding and underutilisation of funds in healthcare, and
c.) Unhealthy market practices by pharmaceutical giants to push the price of medicines.<

Dr Divyesh Mundra, a Masters of Health Administration graduate from the Tata Institute of Social Science and a medical practitioner said, “Many Indians still don’t have access to life-saving drugs. High OOP health expenses due to poor primary healthcare and expensive private healthcare is pushing millions into poverty.”

The 70-70 Paradox

“My brother’s two-year-old daughter has tumor in her liver. We got private treatment in Bihar because government hospitals are in a very bad shape and we didn’t want to take any unwanted risks. But, private treatment put us in a lot of debt and her condition kept deteriorating,” said 25-year-old Munna Kumar Yadav, a casual labourer, from the Aurangabad district in Bihar.

“Finally, last month, we took some more loan from the local moneylender and came to AIIMS,” he added. Munna and her sister-in-law sleep on footpaths outside AIIMS. Hundreds of patients’ relatives, like Munna, are in a similar plight as hospital waiting rooms are running over capacity.

Munna further informed that his brother had to return to his village to arrange more money as they exhausted Rs 10,000 on buying medicines in past 3-4 weeks.

An analysis by PRS Legislative Research, of the government’s data on healthcare expenses, reveals that 70% of the total health expenditure is borne by consumers. Researchers and medical experts refer to it as India’s 70-70 healthcare paradox. A similar study reveals, that out of the 70% expense incurred by consumers, 95% is out-of-pocket expenses, which include medical tests, cost of medicines etc., while only 5% is covered by public or private insurance schemes. With over 80% of the country not covered under any public or private insurance schemes, people in the country are facing the brunt of catastrophic healthcare expenses.

According to Shailaja Chandra, former Secretary to the Ministry of Health &Family Welfare and senior fellow at the Shiv Nadar University, “While in theory anyone can go to a Government dispensary or primary health centre, the opportunity cost of transportation, waiting time to see a doctor, possible non-availability of diagnostic facilities and drugs deter most people. Depending on affordability people go to known private practitioners who take consultation fee. Diagnostics, pathology tests too have to be carried out and drugs purchased as indicated by the practitioners. Altogether the costs are high.”

Lack Of Comprehensive Health Scheme

Several pieces of research, including National Health Surveys, indicate that private and public healthcare schemes, like Rashtriya Swasthya Bima Yojana (RSBY) and Janashree Bima Yojana (JBY), have been ineffective in reducing the out-of-pocket expenditure and providing affordable healthcare. Lack of support for outpatient care, poor implementation, healthcare shifting from primary to secondary or higher levels due to the influence of private sectors, and the inaccessibility of empanelled hospitals for rural residents have been blamed for the failure of such schemes.

Earlier this year, the National Family Health Survey (NFHS-4) acknowledged, that health insurance coverage in India is unsatisfactory. The report disclosed that only 20% of women in India, in the age groups 15-49 and 23% of men age 15-49 are covered by health insurance or a health scheme.

“We have partial insurance schemes that don’t reduce out-of-pocket healthcare expenses. the coverage details of the schemes are in itself a problem. Suppose the scheme covers 1000 procedures and if your condition doesn’t fall into that, you’ll be left high and dry. Many times diseases are detected much later after going through several costly medical procedures, which aren’t covered by insurance,” argued S. Srinivasan, who runs Low Cost Standard Therapeutics and is associated with All India Drug Action Network(AIDAN).

Costly Affair Of Private Healthcare Services

According to World Health Organization, about 68% of the Indian population has limited or no access to essential medicines. Another study by the Public Health Foundation of India (PHFI), the availability of free medicines in public health facilities declined from 31.2% to 8.9% for inpatient care and from 17.8% to 5.9% for outpatient care.

The highest expenditure in out-of-pocket expenses relates to cost of medicines, 52%, which is not covered under any private or public health insurance schemes. With the unavailability of free or low-cost drugs, the unregulated and irrationally overpriced drugs are thriving in the market. This the biggest contributor to the catastrophic healthcare expenditure.

“My 15-month-old son has a hole in his heart. Seeking private health services put us into debt and didn’t yield results.  We then took loan of Rs 1 lakh from local moneylender and came to AIIMS, Delhi. We’ve been here for a month and already spent Rs 10,000 on medicines. Around 6-7 medicines prescribed by the doctors here aren’t available inside the hospital and outside they are very costly,”  said 35-year-old Aarti Devi from Gorakhpur, U.P. Arti Devi and her husband Rakesh are casual labourers and are not covered under any public or private insurance.

Aarti Devis’ situation reflects on how high cost of medicines and private healthcare services are forcing many poor families into avicious cycle of debt.

As per India’s market-based mechanism, the average price of three popular brands decides the ceiling price of a particular drug. This pushes the pharmaceutical companies to resort to unfair means to influence the drug pricing through unfair means like a nexus with doctors to promote a particular brand over the other and encourage irrational drug prescription to expand their market, say experts.

According to reports, pharmaceutical companies pump in around Rs 4,200 crore, into marketing and promotional activities.

“Post liberalisation when markets opened to private sectors, the mechanism to determine drug prices shifted from cost-based mechanism (where actual cost incurred in making the drug used to decide the ceiling price of drugs) to market-based mechanism. This is the major reason behind steep drug prices. Moreover, due to the influence of pharma giants drug prices aren’t covered in insurance,” said Dr Jayaprakash, additional professor and child psychiatrist unit chief in Trivandrum Medical College.

Achieving Universal Health Coverage

Earlier this year, PM Narendra Modi launched the ambitious Ayushman Bharat National Health Protection Mission (NHPM) insurance scheme aimed at covering 50 crore Indians. It will help in achieving the government’s ‘health for all’ target. However, experts and researchers have asserted that the current trends in the Indian healthcare system indicate that the country has a long road in terms of achieving Universal Health Coverage (UHC).

“The increased public sector investments are essential to ensure affordable healthcare. Also, issues like commercialised and unregulated healthcare delivery systems and imbalance in resource allocation also needs to be addressed,” said Dr Mundra.

Commenting on the regulatory aspect, Dr Chandra noted, “The real need is for regulation, enforcement, oversight of responsibilities and zero tolerance for inefficient, cost- ineffective, and irrational medical treatment. That should apply to all practitioners and medical facilities for which guidelines have to be issued every year.”

Achieving affordable health coverage in the world’s second most populous country could be an arduous task and would require coordination from different government agencies. The right step towards universal health coverage would be to increase the government spending on healthcare from 2% to 5-6% of GDP, strengthen PHCs, increase the availability of the free medicines, regulate drug prices, and increase doctor-patient ratio which is 10:10,000 currently.

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

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Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

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MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

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A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

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A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

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A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

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