December 28, 2010 5:24 pm

Healthcare system failing poor Indians

A semi-nomadic shepherd who spends each rainy season grazing his flock in a remote forest in south India recently travelled to the small town of Nagarkurnool to seek medical treatment for a high fever and chills.

In spite of his limited means, B. Ramachandraiah did not visit the dank, dilapidated primary government health centre on the outskirts of the town. Instead, the 50-year-old turned to a 25-bed private clinic, where M. Pullareddy, the physician living upstairs, diagnosed him as suffering from malaria.

For Mr Ramachandraiah’s family, the doctor’s Rs50 ($1.10) consultation fee and Rs200 for blood tests was money well spent. “Nobody is taking care of you in a government hospital,” said the ailing man’s uncle. “Even if we don’t have money, we come and request the doctor to treat us.”

The decision by many poor urban and rural Indians such as Mr Ramachandraiah to opt for private care reflects what Amartya Sen, the Nobel Prize-winning economist, calls the “premature privatisation of healthcare” that is taking place in India amid the de facto collapse of the cash-strapped government system.

With the government in New Delhi spending less than 0.9 per cent of gross domestic product on healthcare – one of the lowest levels of government healthcare spending in the world – public hospitals lack adequate facilities, and medical staff, to cope with surging patient demand.

Indian households shoulder about 80 per cent of the country’s total healthcare burden from their own pockets, an astonishingly high level for a country with so many families living at or below the poverty line.

To Mr Sen, the government’s abdication of a greater role in providing basic healthcare to its impoverished citizens is a “total disaster”, which leaves poorly educated patients vulnerable to potentially unscrupulous practitioners.

“A doctor can tell any story and get a sum of money out of the patient,” he says.

Even when private doctors are highly ethical and trusted in their communities, the high reliance on private practitioners has had another serious consequence: making it virtually impossible for India to accurately assess the true disease burden its population faces.

India has just six doctors and nine hospital beds for every 10,000 of its people, compared with 14 and 30 respectively in China, according to the UN. Most doctors opt for private practice, with higher salaries and better conditions.

The shortage of medical personnel across the public health system is reflected even in the airy new district hospital in Nagarkurnool, in southern Andhra Pradesh state. It is supposed to have 16 full-time doctors but has just nine, none of which is a specialist.

“The doctors’ strength in government hospitals is very weak,” said P. Gopal, a retired district health officer in Nagarkurnool. “People are not interested in work in the government. They should pay better salaries. Only then will doctors come to government service.”

Like so much of its government apparatus, India’s disease reporting and surveillance system is a legacy of its socialist-era past, which only takes into account patients at government healthcare facilities but not those seeking treatment from the private practitioners who increasingly dominate the sector.

The consequences of this were highlighted this year when New Delhi was hit by a severe epidemic of dengue fever but official statistics lagged far behind the true scale of the outbreak, according to doctors in private hospitals.

India’s malaria burden is also widely believed to be similarly underreported. In October The Lancet, the medical journal, published a study calculating that the number of malaria deaths in India may be 10 times higher than the World Health Organisation estimate of about 15,000 per year.

The findings provoked a furore, and vigorous denials from the WHO which questioned the study. But most private doctors agree that India’s official disease statistics are highly unreliable.

In Nagarkurnool, Dr Pullareddy said he saw about 100 fever cases a day during the rainy season, of which 10-20 usually turned out to be malaria. But these are never officially recorded with the government, because of the lack of any policy or procedure.

Such considerations are the last thing patients have on their minds when they turn up at his clinic.

“At the government hospitals, doctors are changing every year,” says Dr Pullareddy.

“But we have been here for 30 years, and all the time we are available. If the patients come in the middle of the night I will come downstairs and I will see them.”

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