The most common “profession” among India’s 800-odd MPs and few thousand MLAs is social work/service, according to their official CVs. Yet, we do not grudge them their salaries and perks — President Ram Nath Kovind recently spoke about how he pays a monthly income tax of Rs 2.75 lakh. We do not hold against mobile manufacturers either that some of them charge over a lakh rupees for a handset. We do not accuse clothing brands of larceny every time we pay a bomb for a dress.
But, a hospital bill is a different proposition. We begrudge senior consultants their fancy salaries; we rue the amount private hospitals charge us — even when it means spending hospital time in a hotel-like ambience. The Supreme Court of India recently lamented the fact that hospitals have become a big industry. The reference was to the hefty hospital bills footed by Covid-19 patients.
There is a problem here — not so much in the business model of private hospitals but in the absence of regulation. The fact that hospitals were allowed to earn profits when the country’s healthcare system had collapsed despite the central and state governments enjoying unbridled powers under the National Disaster Management Act, is a failure of governance. It is also possible to argue that buying a high-end phone or an expensive dress is a choice while healthcare isn’t. But it is the obligation of a government to supply quality healthcare at affordable rates. If government healthcare does not tick those boxes and leaves wide gaps that are filled by the private sector, the blame lies with the government; private hospitals cannot pay the penalty for that.
Article 47 of the Indian Constitution, which lists one of the Directive Principles of State Policy, says: “Duty of the State to raise the level of nutrition and the standard of living and to improve public health: The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health.”
If public health is a responsibility of the State, then inadequate healthcare infrastructure in the country is a result of years of abdication of that responsibility by the State. Had central and state governments fulfilled that duty, perhaps the entry of the private sector in the health sector would not have proven necessary. But that did not happen and no matter how problematic it may sound, a business that employs people, needs investments in latest technology and has to abide by quality standards (which many of the top and most expensive private hospitals do) to sustain itself. At a more micro level, a doctor also needs to repay that education loan she took to acquire that degree abroad. Do we expect her to forego her salary just because she is in a “noble” profession when we do not begrudge our legislators their income?
One may argue that the directive principles are not binding. Here’s a sobering thought — beef bans across states have happened under Article 48, also one of the Directive Principles of State Policy.
Inadequate public infrastructure
An analysis by the Center for Disease Dynamics, Economics & Policy in April 2020 concluded that of the total 18,99,228 hospital beds in India, 11,85,242 are in the private sector and 7,13,986 in the government sector. Of the ICU beds, 59,262 are in the private sector and 35,699 in the public sector.
According to the National Health Profile 2019: “India spends only 1.28% of its GDP (2017-18 BE) as public expenditure on health. Per capita public expenditure on health in nominal terms has gone up from Rs 621 in 2009-10 to Rs 1657 in 2017-18.” The total number of registered allopathic doctors (until 2018) in the public sector was 11,54,686. This means each government hospital doctor in the country caters to a population of over 1,100.
According to the Economic Survey 2020-21, “Around 74 per cent of outpatient care and 65 per cent of hospitalisation care is provided through the private sector in urban India.” That is because the public sector is overcrowded, stretched, often dirty and has no concept of dignity. Patients are herded around, shouted down and generally maltreated — they bear it because the medical treatment is free and they cannot afford any other kind.
A 2007 paper in the Economic and Political Weekly noted that “high absenteeism, low quality in clinical care, low satisfaction levels with care (clinical and with regards to courtesy and amenities) and rampant corruption plague the [public health] system.” Not much has changed over the years.
The fact that rural India is catered to almost entirely by the public sector is not because the public sector is any better off there, but because the private sector is all but absent. That, too, is a governance issue. The private sector was given prime property in cities to set up shop; over the years, there has been scant oversight on whether conditions of the land allotment — in Delhi, for example, it is 25 per cent free beds — are being met, but no effort was made to incentivise the presence of the private sector in villages.
Suggestions about bettering healthcare infrastructure have almost always included the option of public-private partnership (PPP) and one of the proposed models was to link hospitals in cities to those in villages — a group setting one hospital in a lucrative location would also need to set one up in a potentially less profitable environment. One important step in both — increasing the health insurance penetration and regulating private sector healthcare costs — was taken with the launch of the Ayushman Bharat programme in 2018, but it will take some years for it to make any real impact.
Successive governments have chosen to ignore Indians’ right to quality healthcare and the private sector has filled that gap. That does not absolve them of the responsibility, to be honest. But to burden them with morality may be a weight too heavy.
Views are personal.
(Edited by Prashant Dixit)