Diagnosis of a prolapse

A newspaper in Chhattisgarh recently highlighted the high number of hysterectomies being performed in the State, linking it to the roll-out of the Rashtriya Swasthya Bima Yojna (RSBY) insurance scheme. This Central government sponsored health insurance scheme allows the insured to obtain treatment in private hospitals also, where most of the hysterectomies were done.

Even though the absence of reliable statistics makes it difficult to pin down a rational number for hysterectomies in a population, and only an examination of individual cases can reveal if the procedure was necessary or uncalled for, the numbers mentioned in the report (722 hysterectomies over six months in Bilaspur district alone) are high.

Certainly, the phenomenon of an increased utilisation of health services covered by State health insurance schemes is not new. Studies have shown this happening with schemes such as Yeshasvini in Karnataka, Arogyashree in Andhra Pradesh, and Kalaignar in Tamil Nadu. While patients are ready to accept what may be unnecessary interventions mainly because they do not have to pay at the point of care, many providers indulge in excessive interventions since they get paid for each intervention.

That this happens is widely known in medical circles, and States must realise the folly and the risk inherent in such health insurance schemes for secondary/tertiary care — taking away the focus and the resources away from primary care, and inducing unhealthy health-care seeking behaviour and increased role of the unregulated private sector.

The procedure

Let’s start with Chhattisgarh, where, according to the newspaper report, an excessive number of women have had their uterus removed.

We must not forget that there are some really important indications for hysterectomies, and some of them are life-saving. Certain fibroids and other uterine problems can lead to excessive bleeding and consequent anaemia; third degree uterus prolapse, which can cause difficulty in walking, immense pain and discomfort; severe uterine infections that do not respond to any treatment over months; or cancers of the uterus and the ovary. For these reasons, most gynaecologists would recommend the procedure. The bottom line is that some patients do actually need hysterectomies. Also, though most illnesses that merit a hysterectomy increase with the age of a woman, there will be some, as young as 25 to 30 years old who need the procedure. It is not uncommon to see cases of cervical cancer and third degree prolapse of the uterus in women in their twenties in those busy hospitals that see more poor and undernourished communities.

If an impression is created among the people that it is always an unnecessary procedure it will only harm the cause of women’s health. The chaff has to be separated from the grain, lest you crush both.

But, going by the report, there is clearly an induced demand for hysterectomies, with women asking for the procedure almost like patients asking doctors to give them an injection. Why has this been happening? Simply because there is no regulation of the indications, processes and the outcomes of health care.

By deciding to empanel private medical establishments in the RSBY insurance scheme (68 per cent of empanelled hospitals are private according to the RSBY official document) for secondary and tertiary care (not primary care), and to market health-care “packages” with price tag attached, the government has induced a warped health-care pattern. There are no standard treatment guidelines, no regulatory or monitoring body and no system for grievance redressal for patients or the care providers.

There are other problems with the RSBY:

• no support for outpatient care in this scheme despite the fact that out of pocket expenses for outpatient care is the most frequent cause of indebtedness due to private medical care;

• insurance companies are neither interested in ensuring enrolment of all, nor in swift renewal of the cards;

• increasing annual premium rates are increasing the cost of care;

• recent studies have shown that the government is not even allotting enough funds required to pay for claims of all the beneficiaries.

• A quick look at procedural faults in the RSBY tells you the enormous errors committed right from the initial steps of registration. Wrong age ascertainment, wrong names, names being excluded, entire families being missed out because they were not at home when teams went to their home, etc. — making a complete mockery of the process.

On the one hand, people covered by the scheme are going for all kinds of procedures they may not need, and on the other, many people have been left out of the RSBY, raising questions about its claims to be a universal health coverage scheme

The Planning Commission appointed high level expert group on health care (HLEG) has pointed to the dangers of the RSBY, and has suggested universal quality health care free of cost to all, which is provided predominantly by the government and complemented by a well regulated private sector with defined scope, quality, timeliness and compensation.

Government establishments

The role of the government’s own medical colleges and the district hospitals in health care also needs to be examined. Consider the numbers of hysterectomies done by the Ambedkar hospital in Raipur, or by the medical college hospital in Bilaspur under the RSBY in the last three or so years: seven and five respectively. And the Raipur hospital runs a postgraduate programme in obstetrics and gynaecology. Going by these numbers, it would seem that women in Chhattisgarh don’t need hysterectomies at all.

While we should condemn unequivocally unnecessary hysterectomies, the medical college hospitals named stand guilty of abrogating their responsibility — that of providing majority health care to the poor, which pushes them into the arms of a driven-by-profits private sector.

A deliberately poorly functioning public health system makes way for a profit oriented private medical system. In fact, it is an open secret that many faculty members of these medical colleges are in illegal private practice, where they perform the procedures that they should be doing in government hospitals. How can we accept a situation that allows such a weak public health system with two of its three medical college hospitals failing?

The question is how to remedy all this? That’s a huge question, but broadly, the solution lies in the state providing universal, free quality health care.

(Yogesh Jain and Raman Kataria are doctors with Jan Swasthya Sahyog, a group of health professionals running a community based model of primary health care in rural Bilaspur. Dr. Jain was on the High Level Expert Group to develop a blueprint on universal health coverage. JSS has been a reluctant empanelled provider under RSBY in Chhattisgarh. The views expressed here are based on the group’s collective experience.)