Most government hospitals and clinics across the country may be a shabby sight. But for the poor, they are the only affordable medical treatment option available. Yet, a majority of the poor prefer to borrow and go to private health centres, as revealed by the findings of the National Family Health Survey-5 recently released by Health Minister Mansukh Mandaviya.
As per the survey, the number of patients knocking at the doors of public health care facilities has dropped from 55.1% in 2015-16, to 49.9% in 2019-21. Respondents mainly cited “poor quality” of health care to justify their preference for private hospitals and clinics.
A case in example is Kriti Rani, a lower middle class tailor who works from home while her husband ferries passengers at Ghaziabad in his electric auto rickshaw. They are parents to three school going children. When Kriti’s daughter Sunaina developed a problem with her right wrist, she could not be persuaded to take the girl to a government hospital in Delhi where the treatment would be free. The couple borrowed from people they knew, deferred the repayment of EMIs for the EV, and paid the money to a small private health institution, Meenakshi Hospital.
“This place is not free, but I begged the doctor to reduce the charges,” said Kriti Rani. “It is clean. And the process does not take too much time. My sister-in-law had brain surgery here and is fine now. She would have died if she had to wait for her turn in a government hospital”.
Many in Kriti’s position feel that government hospitals are best avoided. Vikram Singh, a factory employee in Noida too borrowed money to pay for his treatment at a private hospital. “I tried a government hospital for one whole week, but their x-ray machine was not working,” said Vikram Singh. “The concerned doctor was not there on another day. When you are employed, you cannot waste time at a sarkari hospital”.
Vikram spent Rs 7000 for the X-rays, injections, medicines and consultation over two visits to a private clinic which he did after his factory timing.
The households survey released by the union health minister also confirmed what Kriti and Vikram are saying. The survey pointed to the long waiting time, inconvenient timings, hospitals and clinics not being nearby and health personnel being absent, to justify their decision to not avail of government health care facilities.
Government schemes not patient friendly
This, despite the taxpayers’ money allocated to healthcare in the public sector growing budget after budget. The increased allocation, according to government statements, is being used to “upgrade” dispensaries, adding more beds and facilities at district hospitals, with many even becoming part of newly opened medical colleges.
The Centre’s expenditure on health care increased from Rs 2.73 lakh crores in 2019-20 to Rs 4.72 lakh crores in 2021-22. In the budget presented in February 2022, the allocation for health in 2022-23 saw a rise of about 16%, to Rs 89,251 crores, with focus on schemes like the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) and the Rashtriya Swasthya Bima Yojana, a medical insurance scheme for Below Poverty Line (BPL) people. This provides for hospitalisation coverage up to Rs 30,000 per family on a payment of Rs 30 towards registration. Importantly, it provides for cashless treatment at both private and government hospitals.
But the schemes are far from patient-friendly in government hospitals.
In fact, this finding in the NFHS-5 survey, about people who most need the subsidised government health care facilities shying away from accessing them, is not a new learning for the government. The National Sample Survey 75th round pertaining to health and conducted between July 2017 and June 2018, also pointed to such a trend: 55% of Indians continue to depend on private healthcare.
Why are public sector healthcare facilities so off-putting? Citizen Matters spoke to Dr Amod Gupta, Professor Emeritus, PGI, Chandigarh, on the subject. Dr Gupta was formerly Dean and Director of the Advanced Eye Care Centre, and has over 45 years of experience in government sector health care at all levels
“The family health survey’s findings that only 46.5% of families in urban areas availed of government sector health facilities in 2019-21 is “absolutely dot on”, says Dr Gupta.
In the course of the interaction, he lists reasons for why that is so, and asserts that it is now time to do a follow up survey that should be an audit on what is wrong and zero in on corrective measures.
Excerpts from the interview:
What is the main reason behind this disenchantment with the public sector hospitals?
First of all, the timings. Government hospitals work like government offices and the working class too have the same work timings. Which means they have to take a day off or suffer wage losses to come to a government facility.
I remember this problem was sought to be corrected by Shatrughan Sinha when he was very briefly Union Health Minister in Prime Minister Vajpayee’s government. For a short while all government hospitals, dispensaries, clinics had evening OPDs. But that was discontinued very quickly.
What would be the other reasons?
A major difficulty the public face is the limited hours the registration counter is open for patients to get their cards. This limited hours registration policy should be reviewed. Government hospitals can always put a cap on the number of patients the different OPDs will see per day, depending on their capacity, so some patients will have to go back. But restricting registration to a couple of hours or three at most results in many patients going back. I have read and heard about patients lining up at the registration counters in the middle of the night to ensure that they are able to get their cards. So getting this card is the most daunting hurdle for many. And then begins the sitting for long hours before one is seen.
Once a minister in Punjab called me, he was desperate for help to get a registration card so that he could be seen by the doctor.
Why is the system like this?
The policies are made from the perspective of the providers, not the consumers. Recently, an officer in Chandigarh went to see what was ailing the anti-encroachment drive. Encroachers who were removed would return in no time, In the end she solved the problem by simply staggering the work hours of those executing the drive. There was no encroachment thereafter. The same staggered timings is needed in government health care facilities too. In fact some 20 or more years ago, some government hospitals did have evening OPDs and clinics — the doctors were given the afternoon off. It worked. Patients want to go to a doctor after their own work hours.
So, these issues discourage the public from accessing govt health care despite its relatively low cost?
In fact, cost is also a big challenge given the prevailing system. In private hospitals, people are able to avail of cash-free treatment through insurance, even if it is a government scheme. Government and government agencies have licensed private hospitals through health insurance agencies, or directly empanelled them, for this cashless facility. This is quick and patients are treated and get back to work quickly without spending time running around to arrange resources to pay for their treatment.
Third Party Agencies (TPAs) take charge of all this and the patient just has to bring the card, get treated and go home. And these arrangements are advertised widely, so people are aware of them. In contrast, in government hospitals, dispensaries and clinics, people lose their day, have to arrange for money, and also face a callous, indifferent staff. Add to this the dirty linen and trash lying all around.
How can the govt address this indifferent attitude?
People in the health sector don’t feel motivated — this is true of technicians, paramedics, nursing staff and other health workers. Only doctors get the name, fame and glory. For the rest, there is no share in that name and fame. They get no credit for saving lives. And so there is no professional pride, no incentive to even keep the place clean.
Lack of accountability, arbitrary behaviour, permanency of the job — all these add to this behaviour. We need major administrative reforms to address all this, particularly to get the supervisory staff to do their job.
Are there other patient-specific reasons for a majority of people preferring private sector health care?
Many. Reports are delayed or lost. MRI/CT scans take a week to get to patients. Some patients travel from far away, particularly to reach the big specialty and superspecialty hospitals. It is easier for them to pay a couple of thousand rupees extra and get it from a private set up.
How can the waiting time be managed?
A word that has become common because of COVID is triaging. It has always been done in the emergency setting. And it was done over the phone during COVID restrictions. It is just about talking to the patient and doing an immediate assessment of what the patient needs: whether immediate admission, tests, consultation and if he can be advised on the spot.
Triaging is possible with a helpline number, through extensive use of information technology. Private sector hospitals are using IT quite a bit. At an eye hospital in Bangalore, they see 1000 patients a day. The patient is allotted a number, receives a message a few minutes before his appointment, and using a barcode or QR code, his time in and out is managed during each stage, every room is registered. If for some reason the patient has not received the message, and arrives at the point where he is supposed to be, he receives an automated voice call.
When Indians are developing all these IT systems and software for the whole world, why can’t we have it in our own government health sector? People shouldn’t be waiting needlessly, at the cost not only of money, but more importantly their health too. That is why the Mohalla clinics of Delhi, providing GP service at the street corner, have been so widely appreciated. At the end of the day, a patient should have a pleasant experience at a hospital, not be humiliated.
It is people who treat patients, so investment has to be more on people in the public healthcare system.
What is the way forward?
Advanced IT infrastructure needs to be brought to the public health care system. Why throng the OPDs when it is possible for a patient to get an sms by way of appointment? That sms does not happen because doctors say they are on rounds and cannot get to their OPD offices at specific times! In teaching hospitals, professors are busy, but assistant professors and those down the line are often sitting idle because they have not been assigned work.
There are so many government schemes for healthcare for the poor…
Yes, there are. But people who need these the most are not aware of them. What we need after these findings is an audit of the awareness of what the public sector healthcare provides — awareness of how to access it, a feedback mechanism without which even the best system will fail.