It was a fortnight back that our 35-year-old neighbour, who suddenly felt unwell, rather late at night, decided to visit the new private hospital which had recently conducted a medical camp at the housing society and even offered a discount card. When the duty doctor, after conducting some tests, informed him that he had been diagnosed with dengue, his wife panicked. The doctor pacified the couple stating that there was no room for any worry and treatment has to be started quickly. While fulfilling the admission process, he was disappointed to know that this hospital wasn’t a network healthcare provider as per his health insurance policy; so, availing the cashless facility was ruled out. But there was no other nearby hospital he could bank upon that too late at night. By the time the admission formalities got over it was past 12.30 a.m. and to his shock found that his health insurance had already expired. To cut the story short, he ended up spending almost a week at the hospital. Despite the hospital offering him some discount, the final bill almost wiped out his bank balance. The learning? Life is short, let us not shorten it with our callous negligence.

But how robust is our health system?

The Indian healthcare system, probably the largest in the world, reportedly has an impressive network of 1,57,819 Sub Centres (SC), 30,579 Primary Health Centres (PHC), 5,951 Community Health Centres (CHC), 1224 Sub-divisional Hospitals, 764 District Hospitals and 307 Medical Colleges. There are about 1.3 million allopathic doctors and 0.8 million AYUSH doctors, including 3.4 million nurses/auxiliary nurse and midwives. State governments are responsible for health under the Seventh Schedule of the Constitution. While NCT Delhi and Puducherry spend 11.2 percent and 9.2 percent of their total state budget on public health respectively, it varies across other states. Notably, there is no single model. 

For instance, if Rajasthan has pioneered with the enactment of its landmark “Right to Health” legislation that guarantees the right to health for all citizens of the state, Tamil Nadu’s, “medical care at the doorstep” scheme in vogue since 2021 aims to prevent a number of non-communicable diseases (NCDs). Karnataka recently launched Health Automated Teller Machines that can carry out over 50 tests totally within 20-30 minutes. While blood pressure and obesity tests can be self-administered, other tests are carried out under the assistance of a nurse and lab technician attached to the government medical facility. Thanks to minimally invasive robotic-assisted surgeries that have been on the rise in public hospitals in Telangana and Delhi, patients opting for them have fewer complications and smaller scars. 

Media reports have from time to time highlighted that visible decline in the service at several government hospitals has been forcing poor people to avail private health care. If a section of public hospital employees lack commitment to their profession and avoid work or remain absent, there are no incentives for efficient workers and disincentives/punishment for inefficiency. There have been instances where some administrators look towards wielding power thereby misusing their position for private benefits. Wherever the system of inspection and monitoring has collapsed, some senior health professionals illegally involve in private practice and neglect their official duties.  

That India suffers a staggering toll of ill-health from communicable diseases, largely resulting from poor environmental health conditions is worrying. There are outbreaks of diseases such as dengue, diarrhoea, hepatitis and even cholera. What is more worrying is that NCDs, such as heart disease and cancer, which are responsible for 63 percent of deaths in the country is on the rise and expected to cost India USD 3.55 trillion in lost economic output between 2012 and 2030. The human impact of NCDs seems to be most severe among those over 30 years old, with cardiovascular diseases being the leading cause of NCD-related deaths at 27 percent followed by chronic respiratory diseases (11 percent), cancers (9 percent), diabetes (3 percent), and other diseases (13 percent); this calls for urgent steps to be taken on a war-footing.

In terms of funding health expenses, according to the Economic Survey 2022-23, almost half of all health spending in India is still paid by patients themselves directly at the point of treatment. Primarily, out-of-pocket expenditure (OOPE) - the money paid directly by households, at the point of receiving health care occurs when services are neither provided free of cost through a government health facility, nor is the individual covered under any public or private insurance or social protection scheme.  According to reports, the mean OOPE for India is estimated to be Rs 14,660. It is higher (Rs 21,564) for children less than a year old. The mean total OOPE (Rs 14,864) was higher among male children as compared to females. The top five OOPE include 43 percent on pharmacies, 28.5 percent on private general hospitals, 7.42 percent on government general hospitals, 6.8 percent on medical and diagnostics and 6.26 percent on providers of patient transportation and emergency rescue. The cost of treatment on an average is significantly higher in the private health sector as compared to public hospitals, which according to news reports caters to 62 percent and 75 percent of inpatient and outpatient cases in the country. Around 18 percent of patients either borrow money (13 percent) from others or sell their physical assets (0.26 percent) or seek contributions from friends, relatives (2 percent) and other sources (2 percent) to meet their hospital expenses. 

Health services, recognised as part and parcel of human rights of citizens are meant to make the society physically and mentally sound. But if your doctor asks you to visit specific diagnostic labs for an array of tests, it can make your cash wallet lighter. Not long ago, income tax raids in Bengaluru had revealed a shocking money-making unholy nexus between some doctors and diagnostic laboratories. Two in-vitro fertilisation (IVF) centres and five diagnostic labs which were raided led to the detection of Rs 1.4 crore in cash and about 3.5 kg of jewellery/bullion, besides foreign currency/foreign deposits running into crores of rupees. It was found that doctors received around 35 per cent of the amounts charged by diagnostic centres for MRI scans and 20 per cent for CT scans as "referral fee" (for recommending patients to medical tests). The same was paid in at least four ways, including fortnightly cash payment and advance cash payment. Notably, such expenditure had been booked by the labs as "marketing expenses" and “professional fees”. 

Last year a division Bench of the Supreme Court disallowed the expenditure of nearly Rs 4.73 crore incurred by Apex Laboratories, a pioneer in zinc-based formulations towards gifting freebies to medical practitioners for creating awareness about its health supplement ‘Zincovit’.

The Bench observed that "medical practitioners have a quasi-fiduciary relationship with their patients...A doctor’s prescription is considered the final word on the medication to be availed by the patient, even if the cost of such medication is unaffordable or barely within the economic reach of the patient – such is the level of trust reposed in doctors. Therefore, it is a matter of great public importance and concern, when it is demonstrated that a doctor’s prescription can be manipulated, and driven by the motive to avail the freebies offered to them by pharmaceutical companies, ranging from gifts such as gold coins, fridges and LCD TVs to funding international trips for vacations or to attend medical conferences. These freebies are technically not ‘free’ – the cost of supplying such freebies is usually factored into the drug, driving prices up, thus creating a perpetual publicly injurious cycle...Thus, pharmaceutical companies’ gifting freebies to doctors, etc. is clearly “prohibited by law”, and not allowed to be claimed as a deduction... Doing so would wholly undermine public policy."

Greed has no limit. It was a couple of years back that a distant (bachelor) relative employed in an outstation city had succumbed to his injuries following a fatal road accident. One of his colleagues who received a phone call and rushed to the public hospital was asked to immediately arrange for about 9 saline bottles from the hospital pharmacy, which he promptly did. Further, he was asked to procure some medicines (as per a handwritten list provided to him by the staff), again, from the hospital pharmacy quickly, which he arranged. Some half-an-hour later, he was told that the patient couldn't be saved and that the body would be handed over after an autopsy was done. The relative's colleague was shocked to find that the saline bottles and medicines which he was asked to arrange on priority were being returned by the same staff to the hospital pharmacy and cash collected, right under his nose.

Following acute stomach pain, my landlord's son who had just celebrated his thirteenth birthday was rushed to the nearby super speciality hospital. It turned out to be appendicitis. Unfortunately, it had burst by the time the admission formalities got over. However, an emergency operation saved his life. Needless to say, the staff at the hospital took good care of the child after the surgery. His father had a health insurance which partially covered the treatment costs. As advised, the child and his mother went to meet the surgeon who operated upon him for a review after a week after discharge. The appointment was taken, the fee paid and they waited for nearly three hours past the appointment time. When their turn came, the doctor, who was all along attending to a guest seated before him who seemed like a medical representative, gave less than a minute for the review. Before the child and his mother, who were still inside his cabin, could clear some doubts, the doctor was found going out to call the next patient. A 2017 study published in the medical journal BMJ Open revealed that compared consultation time in first world countries like Sweden, Norway, USA, which is more than 20 minutes on an average, in India it was just 2 minutes. 

Globally, the pharmaceutical industry aggressively promotes their brand of medicines, ostensibly to change the prescribing habits of physicians. 

Can a doctor compel a patient to buy a costly medicine of a particular brand when cheaper alternatives are available? 

A few months back, in order to personally verify the veracity of complaints related to certain malpractices at the Government Multi Speciality Hospital, Chandigarh, when the then Health Secretary visited the said health institution one night disguised as a patient suffering from abdominal pain, he witnessed the stark reality. In defiance of official directives allowing prescription of only generic medicines to patients at government hospitals, the duty doctor at the Emergency, even without examining the Health Secretary, prescribed him a costly branded medicine (syrup) and told him to procure the same from a chemist shop on the hospital premises. However, the prescribed syrup was available only at one of the three chemist shops and was much costlier than the alternative syrups offered by the other two chemists. It was also found that none of the three chemist shops provided bill on their own but only when persisted. 

More recently a businessman shared a unique experience that one of his employees faced in a corporate hospital. Her teenaged child, who had to undergo treatment in respect of a rare health condition, was insured by her husband under the company's health insurance scheme. The hospital was enlisted for cashless treatment. The hospital initially offered a Rs 6 lakh package for the child’s treatment, on the plea the drug was costly. But later agreed to allow a 40 percent discount with a rider that the cost of the drug had to be paid in cash (outside the insurance) at the in-house pharmacy. On being contacted, the pharma company not only offered a special discount but even agreed to provide the drug for free. However, it was subject the condition that the hospital allowed it to supply the drug directly to the hospital pharmacy, as a drug replacement.

There have been several debates on securing the right to health for all in India, including the gross inequity in health-care delivery and the minimum levels of health care being unavailable to those who are unable to pay. Further, the government's intention to disincentivize the practice of receiving extravagant freebies in exchange for prescribing expensive branded medication over its equally effective generic counterparts, thereby burdening patients with unnecessary costs gets defeated when some unscrupulous elements betray the Hippocratic oath for pecuniary gains. 

It is high time that operational transparency and accountability is urgently brought in our healthcare sector.