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EDITORIALS

A Crisis of Plenty
The poor in India have access to surgeries but not basic healthcare.

ven as the past few decades have witnessed a steady deterioration of public health services in India, health activists and
medical journals, apart from the World Bank, have been
warning about our medical overuse crisis. This crisis has three
main causes: increasing insurance cover, mushrooming of private
hospitals and misuse of the financial provisions of government
health welfare schemes. A recent media report points out that in
the five years between 200910 and 201415, the number of major
surgeries conducted under the National Health Mission (NHM)
has shot up remarkably. This category which includes Caesarean
section (C-section), hysterectomies and other emergency surgeries
has increased by 979% in Maharashtra, 470% in Karnataka,
400% in Bihar, 258% in Jammu and Kashmir, 2,214% in Sikkim,
1,178% in Andaman and Nicobar Islands and 1,501% in Nagaland. What appears on the surface to be increasing access to
health services carries with it not just the risk of the vulnerable
and gullible being cheated financially but also having their
health compromised. The poor and women pay the highest price.
The skewed scenario was further emphasised in 2014 when
the World Bank warned that Indias excessive healthcare situation can harm patients whilst providing marginal benefits. The
Jan Swasthya Abhiyan has pointed to the Rashtriya Swasthya
Bima Yojana (RSBY) which offers below poverty line (BPL) families
a cashless yearly insurance of Rs 30,000 as one of the schemes
which is being misused by unscrupulous doctors. Then there is the
Janani Shishu Suraksha (JSS) programme that offers pregnant
women free delivery and aftercare with free medicines, diet up
to three days or seven days depending on whether it is a normal
delivery or a C-section along with a cash component if they
agree to have an institutional delivery rather than at home. In
Andhra Pradesh when health activists showed that unnecessary
hysterectomies and C-sections were being done to claim money
under the Arogyasri scheme, to its credit the state government
in 2010 revised the rules. Similarly, Chhattisgarhs uterus
scam in which women as young as 20 were subjected to hysterectomies by doctors led to international media attention though
the doctors involved got away with light punitive measures. The
side effects of hysterectomy include osteoporosis, a higher risk of
heart disease and tendency to depression. These poor women
have access to hysterectomies but not to much simpler treatment for their other health issues. The World Health Organization (WHO) has categorically said that the C-section should only

be performed as a life-saving measure and that no region should


have rates higher than 10%15%. However, the national average
for India was 20% in 2015 with states like Kerala showing 30%.
Of course, it is no consolation that countries like China, the
United States and Brazil show high percentages of unnecessary
hysterectomies and C-sections as well. In these countries as
well, health activists and doctors are concerned at the high
rates of these surgeries apart from prescriptions of unnecessary
medical tests and procedures.
As far as India is concerned both surveys and impressionistic
data confirm the rampant resort to unnecessary medical procedures, hospitalisation and surgeries. There is also no dearth of
suggestions on the possible solutions to the crisis. Immediate
attention towards filling the vacancies in primary health centres
(PHCs) so as to reduce the dependence on tertiary-care services
and specialists, strict technical audit of the medical procedures
followed under the government health welfare schemes, greater
regulation of the private healthcare services and private health
and medical insurance schemes are some of the measures that
have been recommended consistently.
However, three areas need to be emphasised. As far back as
2013, the National Consumer Disputes Redressal Forum had asked
the Union Ministry of Health and Family Welfare and the Medical
Council of India to ensure protection of women from rampant
unscrupulous hysterectomies by private nursing homes that
misuse the central welfare schemes. What has been the role of
the Indian Medical Association (IMA) in this state of affairs? Its
own members have urged it time and again to be more proactive on
this issue and play a greater role in dealing with the crisis that has
given the profession a bad name. Second, the government must
ensure greater public awareness about the fact that more medicines and tests do not necessarily mean superior treatment and
healthcare. The most important step must be the strengthening
of the public health services which will also check the rampant
malpractices in the private healthcare sector and arrest the growing
resort to private healthcare. Despite the well-documented, catastrophic consequences of out-of-pocket expenditure on healthcare on the poor, there seems to be a sustained move towards
greater involvement of the private sector and the diminishing of
the role of the government in building this crucial aspect of the
social infrastructure. The least the government can do is ensure
strict monitoring of rules and enforcement of the rule of law.

april 9, 2016

vol lI no 15

EPW

Economic & Political Weekly