“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.”
“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.”
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).
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.
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.