Strange India All Strange Things About India and worldStrange India All Strange Things About India and world



Even as many Indian hospitals invite a foreign clientele to world-class treatment facilities, the poor have to contend with a different and unregulated private sector, says
Abhijit Das.

01 March 2004

India is emerging as a favoured destination for a new kind of tourism – medical
tourism. While states like Goa and Kerala are trying to woo the foreign tourist with their natural
splendours, many Indian hospitals are trying to invite a foreign clientele with five star hospitality
and world-class treatment facilities. The slow trickle of foreign patients’ promises to turn into a
flood; this industry is reported to be growing at 15% annually. This should sound like music to
our ears too. Shouldn’t we Indians all be proud that our hospitals and doctors are becoming popular
not only with our cousins across the borders but also for patients all the way from the Middle-east
and even the United Kingdom?

The image of a globally competitive Indian industry is being fed daily to all
citizens of this country in so many different ways. We first learnt of the distinct edge that the
Indian software engineers and firms had over their western counterparts before the now forgotten Y2K
episode. Then it was boom time for the call-centre industry and now for a whole range of services
called BPO. Some time ago we also learnt of how the Indian educational system notably the Indian
Institutes of Technology and the Indian Institutes of Management could rub shoulders with the best in
the business, globally. And now we learn that the Indian health sector is so good that a person in
Manchester doesn’t think twice before getting her or his knee replaced by a hotshot Indian doctor in
a five star Indian hospital in Mumbai.

Indeed, we have more advanced health care now than we’ve ever had. Our private
hospitals are comparable to the best in the world, where their equipment and facilities are
concerned. Our drug companies are filing for global patents and have become a force to reckon with in
the international markets. Hundreds and thousands of young Indian doctors leave these shores to train
abroad. Many stay back in their adopted countries but many return and start working in the world
class hospitals which are now found in all large Indian cities.

What is a matter of grave shame though is that despite such ‘achievements’, an
overwhelming proportion of Indians do not have any access to reliable health care services. And if
there is one sector in which the schism between Bharat and India is the widest and deepest it is in
the health care sector. While the Constitution claims that India is a ‘socialist republic’ it has
perhaps the most privatized health care system of the world, even more than ‘capitalist’ USA. This
has an almost catastrophic consequence for the poor Indian. While the number of primary health
centres across the country is impressive, in most places the services are unavailable. Even ten years
after coming up with plans for making emergency obstetric care available to the poor the systems are
still not in place. The name of the scheme, however, has undergone two or three metamorphoses and in
the meantime the maternal mortality rates continue to rise.

A World Bank study on the Indian public health system concluded a few years ago that
most people who visit the government health facility can afford to pay. Moreover since over 80% of
all health care expenses come out of private pockets, it was mooted that Government health care
facilities should not remain free, and user’s fee was introduced. It was a misnomer to call
government services ‘free’ in the first place. The poor in India also pay taxes, and as tax payers,
it can be their minimum expectation to receive some basic services. Secondly the poor patients pay a
hefty unofficial service charge for all the services they receive at government hospitals – from the
tip to the ward boy to clean the urinal, to a ‘fee’ to the surgeon for removing an appendix.
Unfortunately the large multi-state studies do not adequately explore this phenomenon.

The All India Institute of Medical Service (AIIMS) is supposed to be the acme of
medical care in India and the Central Government is often promising AIIMS-like facilities in other
states as well. The promise sounds good, but only till the time you realize the way poor patients are
treated at AIIMS. Before private hospitals became the popular haunt for prime ministers, it was AIIMS
which used to be the favourite health destination for our political masters. Even now a quick
appointment, an immediate investigation or timely surgery require political connections and clout.
For the poor these state-of-the-art, free facilities are available through the welfare state – but at
a cost. Long delays at every counter, month-long waiting lists, frequent breakdown of equipment, etc.
make it certain that other than the most persevering patient others soon make a bee-line to a private
facility.

The private sector that the poor have to contend with is not the flashy
Apollo Hospitals but the unregulated private practitioners found in all small towns.

India Together: Competitive but inaccessible - 01 March 2004 1

Nowadays it is fashionable to say that government services are ‘weak, inefficient,
and corrupt’ and hence dispensable and privatisation is the way to go. Unfortunately the private sector that the poor have to contend with is not the flashy Apollo Hospitals but the unregulated private practitioners found in all small towns and in all localities in the larger ones. Many of them hold valid medical degrees, many don’t. But other than this distinction, the quality that all of them have in common is to over-prescribe and to practice the most irrational forms of clinical medicine. There are no standards of practice, no common protocols, no norms, no regulations, and fees are charged in the most arbitrary manner. However these services are competitive and manage to cure many of their ‘clients’ and their fame grows by the day through word-of-mouth as well as not-so-subtle hoardings and banners.

In India the doctor is held in great reverence and s/he occupies a berth slightly
lower than the gods in the family pantheon. And despite a large shortfall of doctors in rural areas,
urban India is teeming with qualified practitioners. This should be good news for the average urban
citizen who can now be certain of being in good hands when the need arises. However the facts
emerging from the latest round of the census shows doctors in very poor light – as being greedy and
without ethics. An ultra sound examination during pregnancy is necessary in certain conditions, but
unscrupulous doctors had made it a mandatory test. Bending backwards to client needs the doctors used
the ultrasound to check for the sex of the foetus. The radiologists in collusion with the
gynaecologists set up large rackets all over the country for aborting the girl child. It is
mind-boggling to calculate the economics of this business where even if a thousand rupees were made
for each test-abortion the total amount made by doctors every year amounts to thousands of crores!

If this is also a picture of the Indian health sector, I wonder if ‘India is Shining’? And even if it is, for whom?

Abhijit Das works on public health and human rights issues, and is associated with various organizations, networks, grassroots groups and related campaigns. He has been a Fellow in Population Innovations of the MacArthur Foundation and a Fellow of the Population Leadership Program of the University of Washington, Seattle.





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