Poverty and its alleviation has been, perhaps, the most recurrent theme in India’s political discourse since independence. Yet, an oft-ignored fact for those interested in poverty alleviation is that catastrophic health expenses are the biggest reason for pushing individuals and families into poverty. The poor cannot afford to be sick because they cannot afford to get well.
This raises some critical questions. Why do the poor have such dismal access to healthcare? Why is it that our investments in the health system are so unimpressive? Perhaps the most critical question is this: why do close to 70 per cent of India’s sick, mostly belonging to the poor or lower middle class, choose to go to the private sector when there is ostensibly free healthcare in the public system?
Lacunae in the system A study done a decade ago answered some of these questions. It clearly demonstrated the lacunae in the public health system including poor quality of care, long waiting lines, patient maltreatment and neglect. The patients that chose to go to the private sector did so for a perceived quality of care. What does this tell us? First, sick people, however poor, need diagnosis but they also need a sense of care. Second, the poor are discriminating, if uninformed, consumers of services including health care. They will pay to get care which gets them back to work rather than wait.
Yet sickness is such a state that even the most discriminating consumers can be exploited. Imagine you are a poor person living in an urban slum with a cough and fever. After ignoring it for weeks you decide to seek help. Initially you try the government health centre. This, you realise quickly, is not an option if you are a migrant worker or a daily wager. So you end up in the private sector. In all probability your local slum doctor will be a quack. The treatment you will receive will possibly be inappropriate. You may feel better briefly or get sicker with time — it’s a matter of time. But you will go back because your options and time are both limited.
If you are lucky and can afford it, you might actually get to see a real doctor, though not necessarily with the best outcomes. For starters, you may be asked to do a battery of tests. The tests can be done only from particular labs to ensure reliable quality and kickbacks. If the tests are clear, pray to whichever god you worship. If, however, you have a common disease like tuberculosis, the nightmare has just begun.
If the realisation that you have TB or another such ailment doesn’t terrify you, the expenses will. By this time you will have probably spent your savings and are in or about to be in debt. However, there is still no guarantee of appropriate treatment or complete recovery. If you do get the right treatment, the drugs may have side affects and you may not be able to work for days. This will make you poorer. Additionally, you will need a diet that you may never be able to afford. At this point, you will have few choices — either to discontinue treatment, go further into debt or go to the public sector — and wait.
This journey is instructive in many ways about the poor’s ability to access healthcare. For one, the common man cannot really access the public health system easily. Though well intentioned, it is over burdened and slow and insensitive. It needs investment and possibly a complete restructuring to make it accessible. The alternative is an exploitative private sector, where appropriate diagnosis and treatment and recovery is not necessarily guaranteed.
Ending the trust deficit Its important at this point to ask what the role of government in this is. Is the goal of the public sector disease control or just providing free health services? If it is the former, then the efficiency, the quality of care and the accessibility of the public sector has to improve. The government needs to restructure how it plans and delivers services and also how these services are perceived by the consumers. The trust deficit must end.
Similarly, the private sector must be innovatively engaged to become part of the solution. The government must ensure that this sector is regulated and monitored effectively. The overuse of diagnostics, over-the-counter sale of drugs and the rising numbers of quacks must be checked immediately. The onus is more on the government to build a mutually beneficial relationship with the private sector.
To the cynics this may seem impossible, but it is not. Previous experiments provide valuable lessons in all these areas. There is enough national and international expertise available to help us relaunch public health services.
Finally, beyond the technicalities we must be guided by the simple realisation that until we choose to change the way the poor access health care, it is unlikely that we will be able to change their poverty status. They will continue to be vulnerable and sick but also consequently poor.
(Chapal Mehra is an independent New Delhi-based writer.)
