Unhealthy situation

KUNAL SARKAR

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THE state of health care in one part of the country is perhaps not very different from any other. It is not the story of uniformity of a system; rather a tale of scarcity of resources across the board, aggravated by an endemically poor administration. For a country struggling to spend more than 6% GDP on health, the options are somewhat limited. Not surprisingly, this is reflected in our shabby health indices, amongst all the BRICS nations, not considering the G7. More than half of this 6% is out of pocket expenses; the actual governmental contribution is a pitiful 3%.

Despite their scarcely, the resources are farcically administered. Health being torn between the Centre and the state, frequently falls between two stools. The policies and preambles are formulated in Delhi, with central allocation of funds. State governments with their inputs are responsible for execution. Not infrequently, the implementation is half-hearted and accountability non-existent. If the Centre-state relations are not amiable, as has been the case with West Bengal, more often than not poor execution is regularly camouflaged by political diatribes. In the unending spree of one-upmanship and dramatics, ground realities have essentially remained unchanged. One is tempted to conclude that the lopsided divide between policy and execution is perhaps a ploy to cook up a train of excuses for the shoddy state of affairs. Thus a leaky system with a poor record of implementation creaks along.

This state of affairs is highlighted in most health welfare allocations being either unspent or ineffectively spent, the biggest casualty being the BPL (below poverty line) health schemes. Meant for the poor, they have even excluded government hospitals, where allegedly most of the poor seek treatment. Identification of BPL beneficiaries and reimbursement of the empanelled facilities is yet another problem. Caught in the entanglement, these schemes, though conceived as game changers, have had little impact in West Bengal. There is an overwhelming belief that they have gone the way of many other schemes – mostly in the pockets of the party faithful. Sadly for the state, it has been an opportunity lost.

 

The characteristic that identifies Bengal is its ability to survive despite the severe fiscal anaemia. If some of the statistical lacquer is removed, it undoubtedly has the lowest income of all the major states. It is not very dissimilar from the millions of anaemic mothers who go on to unattended childbirth and yet survive. It is a feat of endurance, no credit to planning or policy. Kolkata survives as a large market town, whose every avenue of value addition has been strangled. Manufacturing is a distant dream, education is an arena for party thugs, and enterprise consists of new avenues of political banality. Make no mistake, it is a continuance of the same theatre of the absurd over 36 years. The new Left and the old Left are united in their lack of pragmatism.

The drying up of survival lifelines is an established reality. For West Bengal, it is a Life of Pi every day – only that the tiger is mad and rabid and we have not had the good fortune for Richard Parker to keep us company.

It is hardly a surprise that people seek health care much too late. There is a growing lack of parity between the incidence of disease and reporting to doctors. We tend to self-medicate and act on the advice of pharmacy wallahs. The national health surveys continue to be surprised by the low rate of those seeking medical advice.

The reasons are obvious. By one estimate, 80% of the rural medical consultations are with ‘quacks’. It would not be an exaggeration to acknowledge them as being the backbone of primary health care. Most health surveys will categorize them as ‘private practitioners’, with doubtful qualifications. One must admit, however, that given the limitations they do a pretty good job, and if not for them the fatalities from communicable diseases would have been worse. They charge the patient anywhere between 30 to 100 rupees, depending upon the medicines dispensed. There is also a lingering fear that some of the spurious medicine supply chain finds its way in through this system. Still, something is indeed better than nothing.

 

Primary health centres are geographically well distributed, but generally ineffective. Facilities are pitiful, absenteeism is rampant and diagnostic back up either for blood tests, ECG and so on is non-existent, of very limited use either for diagnostic or treatment purposes. Common conditions like fever, chest pain, abdominal pain, child birth are a challenge for these rickety facilities. So most people are resigned to the fact that if they have to seek meaningful intervention, it has to be either in the district or private hospitals. Though on paper the primary health centres are plentiful in number, they essentially remain toothless. What is lacking is a basic definition of what constitutes the essential needs of a community. The mere presence of a doctor in a concrete shed without facilities for diagnosis or treatment is a financial waste. The PHCs of the 1960s urgently need upgrading to meet the basic needs of today.

One hopes we are still not deluding ourselves by physically positioning a doctor, who at best has a 50% attendance record, without the essentials of treatment. This is the first step wherein the Bengali loses faith in the government and its local systems and seeks treatment is distant hospitals. Given the pathetic economic state of the countryside at large, it is hard to imagine private nursing homes being set up outside of district towns. At the end of it all, either the quack sets you right or you embark on a taxing tour to distant shores in search of a cure.

A glance at the health numbers, e.g., the infant mortality rate in West Bengal, in comparison with the rest of the country, is not bad. But, one has to realize that India’s infant mortality indices are rather poor, far worse than those prevailing in Bangladesh, Sri Lanka and Afghanistan. So, we are often worse off than the rest. Bengal still struggles with a large proportion of mothers who do not deliver in hospitals or nursing homes. An unacceptably large number of deliveries are at home, virtually unsupervised. This, not unexpectedly, results in high maternal and neo-natal mortality. There are incentive schemes to promote institutional deliveries, but that again depends on an unorganized private sector for implementation.

 

The condition of the district and teaching hospitals is as good or as bad as their counterparts elsewhere. Early in the 1980s, under the glare of the World Bank, there were fundamental restrictions imposed on the medicines dispensed and number of free beds. A charge for outpatients was also introduced. It is from that juncture that medical care in the government hospitals was not so ‘free’ after all.

Though initially one expected state hospitals to be more cost effective, in reality it is the reverse. Hospitals are surrounded by a host of medicine and supply shops, who extract their due, ranging from a gram of cotton wool to the most expensive antibiotics. So, the bed or doctors charges notwithstanding, the expense on medicines is punishing. By many accounts a large portion is not utilized and recirculation through the same shops is not uncommon. The itemization and accountability of medicines and consumables cannot be implemented in government hospitals in the near future for a lack of IT capability. The pharmacies and manufacturers have made a mockery of the MRP (maximum retail price) business. Discounts and premiums have made the transactions murky. The government has responded by setting up ‘fair price shops’, thereby admitting that the trade in medicines is entirely unfair. The contradiction notwithstanding, such shops are far too few to make an impact.

 

Unequipped primary and secondary facilities make the volume of referrals to the teaching hospitals too large to handle. In fact, even the non-Kolkata medical colleges are in the habit of referring patients to Kolkata hospitals. Burdened with a sea of humanity, the tertiary hospitals are struggling both for quality and quantity. This is reflected in the periodic upsurge of child deaths, most of whom have travelled for days to seek treatment that should have been available nearer to home.

A poor marshalling of resources adds to the despondency in the medical college hospitals. Medical, fiscal and human resources are administered as in any other tardy arm of the state machinery. So the talent and expertise that is available is perhaps not even fractionally utilized. Medical colleges basically function on the heroics of the junior doctors and middle grade staff. If it were not for their selflessness and eagerness to gather experience, the emergency and operating loads would be impossible to manage. In the elective setting, involving the senior consultants, it is a sorry tale of under-productivity.

Without reasonable manpower and equipment, tertiary departments consistently perform less than half the number of procedures in comparable private set ups. Manpower management, equipment maintenance, and grappling with unions are genuine retardants. However, this is probably still not enough to explain the severity of underutilization of resources. A lack of performance incentives and using the system of transfer as a punitive measure has in addition traditionally eroded the consultant’s enthusiasm.

The transfer system is usually run on the Stalinisitic principle of doctors being cast off to remote locations based on their relationship with the political and bureaucratic system. It is impossible for a professional who values medicine more than politics to survive in this quagmire. Recently, a professor of neonatology was transferred to a primitive outpost without a paediatric bed, based on the crime and punishment principle. With little prospect of narcissistic HR practices abating, it would be foolish to expect an elevation of morale and utilization of human capital. The cancer perpetuates irrespective of the political czar in command.

 

At various times there is a show of initiative focused on specific disciplines. West Bengal has one of the largest facilities for interventional cardiology in government hospitals. Most of them function at a decent level of efficiency. Laudable as it is, some of it may be ascribed to the commercial sweeteners associated with cardiology disposables. In response to public outrage over child deaths, expansion of paediatric intensive care has commenced, though it is out of sync with the manpower available and there are abundant examples of unmanned units where the equipment is lying to rust. In the foreseeable future, productivity and resource utilization is hardly likely to improve in the absence of rapid decentralization and professional apolitical management.

Health care is a popular platform and a vote bank vending machine that no party wants to lose control of. As long as scarcity can be exploited, who cares for satiety? A crucial question to ponder, in the national context, is whether state governments should re-focus from being health care providers to insurance providers? Arguably an extensive insurance cover would enable better use of under-utilized capacity in the private infrastructure. As the government hospitals are packed like sardines, many private hospitals function on a 50 to 60% capacity utilization.

 

In spite of being a communist ruled state for over three decades, and now under an ultra-populist regime, population based health insurance has been conspicuous by its absence. It is baffling that an otherwise volatile electorate has not demanded this over the past decades – probably an exposition of the typical dominance of heart over head? There are very few whispers from any party in this direction, probably in awe of the staggering levels of bankruptcy. In the near future, the prospects for a scheme in line of Yashashwini (Karnataka) or Aryogyashri (Andhra) appear remote. We are destined to seek salvation in street corner fist fights.

The evolution of a private sector in Bengal was late and slow. Possibly it has to be understood in an historical perspective that colonial powers did not deem it important enough for the non-urban population to have access to health care. Consequently, there was little health care penetration outside of Kolkata in the pre-independence era. The four principal medical colleges in Calcutta were showpiece centres, completely out of bounds for the teeming humanity. They, in fact, functioned thus, till the sixties. As access and aspiration increased, under the stress of numbers, the quality of these facilities wilted. The first private hospital was established as late as 1965. By this time small nursing homes had mushroomed with better furniture than equipment. It also took Bengal decades to break free from the worship of individuals at the cost of systems. Absurd as it may seem, demigods of medicine even obstructed the introduction of CT scanners and endoscopy for fear of being threatened with obsolescence.

 

The seventies and eighties were the dark decades for medicine in Bengal. During this time it was firmly encrypted in the Bengali DNA that at the first hint of a problem one was expected to take the train to Chennai and Vellore. Even as a consolidated structure and system of health care was emerging elsewhere, it was only available in small pockets of mediocrity and exploitation in Bengal. No doubt, all and sundry were fed up with the state of affairs. This must be seen in the context of the carnage the militant Left has raged in the industrial sector. In the face of militant trade-unionism, there was no investment at all in a manpower intensive sector such as health care.

Somehow even the lethargic communists relented in the late eighties and early nineties, leading to a trickle of initiatives, both from NRI investors and native capital. The early nineties saw quality hospitals being established, creating an opportunity for some quality expertise to be attracted back into the state. The nineties were a good time for private enterprise in health care. But economic stagnancy of the state remained a road block in the path of continued investment. With the turmoil and supreme ambiguity regarding the land allocation policy of the past two years, this major initiative has been effectively stymied. In fact, none of the all-India groups like Apollo, Fortis and Narayana have so far shown any inclination for real time expansion in the state.

 

The average revenues in West Bengal hospitals are among the lowest in the country, as the cost of various procedures is artificially controlled keeping an eye on the desperate state of the economy. Corporate and insurance patients account for less than half of comparable revenue that accrues to this sector in any other major state. With stagnant revenues and slow fiscal growth, competing at the national level for manpower remains a stiff challenge. A large proportion of the technical and supportive manpower have a high attrition rate. This is aggravated by the fact that West Bengal trains less than a third of its nursing and paramedical staff. The perpetual dependence on nurses from the South and Northeast of the country is tough to sustain. The expertise equalization that was initiated in the last decade, especially in the areas of cardiac care, neurosurgery, laparoscopy and so on will be difficult to sustain if support from the industry dries up.

One glaring example of lost opportunity was the turn of events which contributed to Kolkata losing its dominant share of medical tourism from Bangladesh. In the years following the liberation of Bangladesh and the bonhomie with India, Kolkata was awash with a flow of patients seeking treatment. The facilities in Bangladesh were virtually non-existent and unsurprisingly even the mediocre establishments in Kolkata seemed good enough. Over the next decades, however, the fluctuations in political relationship and draconian visa procedures proved a significant hindrance to the medical traffic.

Cynics often allege a conspiracy by the central government against a flourishing health care industry in Bengal. But neither did we help ourselves in failing to upgrade the systems and services adequately. The financial dealings with patients from across the border were far from justifiable, an apt parallel of slaying the golden goose. As we were lapsing into the slumber of complacency, giant strides were taken by Thailand and Singapore to attract the cream of the clientele. Presently only a fraction of the Bangladesh business finds its way to Kolkata. It will be difficult to now turn the tide unless there are rapid value additions to the industry.

 

Dwelling on issues as we have over the past few pages, the sentimental Bengali would lapse into historical nostalgia, reminding all those who care to listen that Bengal was the birthplace of modern medical education in Asia and the Mecca of medicine for two decades after independence. Sadly, that equity was not strong enough to sustain the industrial plunder and the opera of annihilation that followed. As residents of this state of strife, we cannot at this moment stake our claim to an abundance of optimism.

The deadly virus that threatens health care in the country at large is the malady of selective socialism. As 80% of health care revenues are generated in the private sector, under duress from the state insurance schemes and political populism, absolute revenue shrinkage is unavoidable. This has resulted in low pay scales for personnel and diminishing margins for the industry. As with every other walk of life that operates in the free market, this socialistic seclusion for health care in unrealistic. We do not mind a welfare state, but that being established on the grave of the health care industry is perhaps not desirable.

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