I was told in my childhood, ‘health is wealth’. I remember my father was so strict about daily exercise that if we brothers do not go for morning jog we were not allowed to take breakfasts. Based on our stamina he had assigned a number of rounds for us and we were to complete those many rounds. No excuses were acceptable. We were fortunate to live in Gandhi Sagar, Madhya Pradesh in a government colony and we were brought up in a very healthy, hygienic and serene environments of Chambal Ghati.
For past 32 years Mumbai has become my home. I live in Juhu scheme which is supposed to be one of the best areas in Mumbai to live in. It is surrounded by Mumbai’s jewels of slums and nallahs. These nallahs make their presence felt and even from a distance of 500 meters you can smell them. But there are people who just do not mind these smells and have occupied both the banks and have created their hutments. There are more people living in those hutments than people in high rise buildings. I am sure their hygienic condition is world class and no one in the government is worried about their health!
In our country the word ‘hygiene’ has no meaning. We do not teach our students about hygienic living conditions neither we teach our children the importance of hygienic living. It is only when we are accompanied by some foreign nationals we become embarrassed when they notice these conditions. But we applaud when someone makes a movie ‘Slum-dog millionaire’ and goes on to win Oscar award.
If you just take an aerial survey of Mumbai you will find that more than 70% of human habitat is made of slums and hutments with no concern for health and hygiene. I am sure every other city in India is competing with Mumbai in creating bigger and better slums!If this is the condition of ‘glamour city’ Mumbai we can imagine what is going on in other towns and villages. And Modiji wants to convert these unhygienic cities and towns into ‘smart cities’!!
Talking about health care in such living conditions may seem like a propaganda. There are always long queues of patients in the clinics near slums with basic ailments like diarrhoea, cold, fever. We have created the best conditions for mosquitoes to thrive and then we complain about malaria!
But there is a health ministry in the government and they are duty bound to spend money allocated to them in the annual budget. Therefore we have government hospitals, municipal hospitals where in the name of health care some activities are done sometimes without medicines. The poor state of governmental healthcare system has been the result of total apathy over the years. This is a clear case of bad monitoring and "corruption" in the system.Government of India considers as its duty to provide primary healthcare to its citizens. In the scheme of things it is the duty of the state governments to provide this service. Central government is supposed to contribute to family welfare and disease control programs. When we look at the role of the government in health care, we find three clear deficiencies. First, there has been absolutely inadequate investment in the public health infrastructure which provides a very low coverage to the poor.
Secondly, government has failed to monitor the operations of dispensaries and hospitals run by it. There are few doctors in the hospitals and those who are recruited have their priorities elsewhere. They are happy to provide consultancy in their private capacity and in their private time but are not willing to show the same level of skill during their duty hours. Third, due to lack of qualified doctors in interior areas of the country, quacks have a field day. There is no efficient and effective mechanism to get rid of these quacks. They are accepted in the system because they fill the gaps in the healthcare system.
These three things have ruined the health and economic conditions of the rural poor. They spend from whatever resources they have for their health but suffer due to incompetence of the system. They get hit in both ways: by the continuation of their illness and total economic ruination.
It is not that people who are entrusted with this responsibility do not know about it. They simply do not care. They have a pensionable job and good enough resources to take care of their family needs. They are not worried by the repeated visits these rural poor make to various hospitals and finally landing in the trap of a private hospital. They take pride in the long queues of the government hospitals because it inflates their number to be submitted to the government. That they are providing health care to so many people.
A poor patient, without any connections to the influential, waits for registration, faces the impact of inadequate supply of drugs and lack of treatment facilities. Staff in these hospitals come and go at their own free will and remain indifferent towards poor patients.There is no stated policy for the role of private sector in the provision of health care. Private practice by doctors, private health care clinics and super-speciality hospitals have grown in a big way to fill the void created by inefficient government sector. Most of the private practice is in the hands of doctors who treat this as another profession to make money and have created systems of cut-practice (sharing money on referrals). If any patient reaches them for health problems he gets treatment but at a higher cost – because he is the most welcome source for funding EMIs for the car and house.
Private hospitals and nursing homes run like business ventures. They look at the occupancy levels of their beds like a hotel. Because occupied beds generate revenue for the doctors and the hospital itself. They will go to any extent to keep these occupancy levels high – even admitting patients when clearly not required.
There is a network of private practitioners, diagnostic centres and private hospitals who feed each other. They thrive on the need of the patients. These patients cough up huge amounts of money for basic health care. It does not matter to those who can afford the cost. They would never visit a government or a municipal hospital because there is a huge difference in the level of cleanliness and hygiene in the private hospitals and government hospitals.We can see the tremendous gap in the healthcare services available to rural and urban Indians. We can see world-class five-star hospitals in various cities across the country. We can hear the talk of encouraging medical tourism for the foreign nationals. At the same time facilities in rural India deteriorates.
The rural healthcare service delivery has been severely compromised. Major advances in medical science have hardly touched the rural poor. They continue to die in large numbers from preventable illnesses like tuberculosis, gastroenteritis and malaria.
Most of this private practice is concentrated in big cities because it provides a good catchment area for doctors where patients have paying capability. Rarely will we find qualified and good doctors practising in villages and tribal areas. Poor in villages can hardly afford the cost of hospitalization. One major illness in the family destroys the financial security of the whole family. Many farmers have committed suicide because they could not pay back loans which was utilized for taking care for the sick in the family rather than for productive purposes. One major illness pushes the family in the debt trap. The lack of trust between patients and doctors/hospitals has reached alarming proportions. No doctor can survive in practice today without insuring his practice. Governments need to create a good infrastructure to bridge this trust deficit.
There is a need to involve private sector in a big way in creation of health care infrastructure which provides health care facilities at the affordable cost. There are industries in many districts of the country. These people have created hospitals and dispensaries for their own staff. These business houses may be involved to support cluster of villages and district hospitals. With the passing of new companies bill in the parliament where there is a provision of corporate social responsibility, companies may be asked to participate in this private-public health care system.
Companies will benefit by earning goodwill of the local population. The country will get an affordable and efficient health care system.
All these efforts will be of hardly any use if we continue to have lack of good sanitation and safe drinking water. There is a need to distinguish between health and health care. If we do not provide healthy living conditions – which is the precondition to good health, all efforts in providing good health care would remain inadequate.
If we do not make our health care system affordable soon we will be in the trap of health insurance companies. Insurance business can expand only if the health care is too expensive. If governments do not create affordable health care service now they will be forced to pay for insurance of people below poverty line. The money which could be used for creating infrastructure will be sucked into financing the health care system.
Because health care has not been an election issue, politicians once elected rarely pay any attention to it. Citizens will have to be aggressive to bring ‘Achche Din’ in the health sector. They need to pressurize political leaders to create well maintained, well-staffed and functioning health infrastructure at all levels. This only can help break the cycle of poverty and disease. Greater access to health care facilities will help improve health as well as economic conditions of the poor. The time has come to reclaim public health and make a paradigm shift from a policy-based entitlement for healthcare to a rights based entitlement. And please do not enact another law for ‘right to health’. We have to create sensitivity in the minds of the political class. We do not want health care on the paper but on the ground.
We don’t want to convert demographic dividend into the largest sick reserve of the world. We must grasp the urgency to provide a good health care and hygienic environment to all the citizens of the country. This is the only way to bring ‘Achche Din’ for good health of Indian citizens and overcome health care hazards.
