Monday, July 06, 2015

Health care in India - making the poor pay

A few days ago, I visited a government hospital in Bangalore. The staff we talked to were unusually open and frank - possibly because some are new hires! I will give no specifics about this facility to protect them, but also because the problems they face are not unique.

The building has been recently renovated using crores of rupees, but there is barely any furniture, even for the staff. The operation theatre is not functional because of poor planning and construction, so while specialists are on staff, even minor operations cannot be conducted. For these expenses, the doctors were waiting for the release of Arogya Raksha Samiti (ARS) funds - these are untied funds that are to be used for repairs, emergency medicine purchases etc. We said that these were construction-related issues, so why should ARS funds be used for them? They said that they had asked the MLA and corporator, but hadn't received any support as yet, so this was their only recourse.

The hospital has a functional lab and lab technician, but only pregnancy and HIV tests are being conducted. For other tests such as thyroid and haemoglobin tests, reagents are required which have to be purchased. The hospital started collecting user fees recently and these will be used subsequently for such purchases. The one fund that they do have in abundance is the one for maternity benefits, which amount to Rs. 2000 per BPL (Below Poverty Line) woman, paid out in 3 instalments. The on-duty doctor mentioned that she had been generous in handing out these cheques earlier, disregarding some documentation requirements if the woman seemed genuinely poor. Also, she was allowing the woman's relatives to collect the final cheque (which had to be collected after delivery within a month). After all, the cheque is in the woman's name. But an audit of the hospital had generated multiple objections. The auditor had said that the documentation was incomplete and the signatures in the register did not match! The doctor said she would have to be more strict in the future.

The latest round (71st) of NSS data collected in 2014 shows that rural families spent, on an average ₹1587 for childbirth in a government hospital and urban families ₹2117. Major expenses include ultrasound scans (3 are required during pregnancy) and diagnostic tests, which are done in private labs. Neo-liberal economists and policy-makers might argue that these expenses are reimbursed for BPL families through maternity benefits, but as shown above the requirements get tougher and tougher for beneficiaries. Further, are only BPL card holders poor or vulnerable? Wouldn't it be cheaper and simpler to provide all these diagnostics under one roof? And user fees, among the most regressive forms of taxation (this actually discourages people from seeking essential health care, further impoverishing them) are being used to buy essential products!

I also realized how staff, especially the dedicated (of fresh!) ones, interpret the expenses of the hospital and its sources of revenue. They have little to no control over the funding from above. All they have are the user fees. One example - the fee for a rabies injection is ₹ 100 - apparently half goes to the department and half stays with them. Along with patients, front-line staff are also made responsible for funding health care! 

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