The Indian Metropolis: Excerpt: Free Chapter Read

ON HEATHCARE

‘Seeing modern health care from the other side, I can say that it is clearly not set up for the patient. It is frequently a poor arrangement for doctors as well, but that does not mitigate how little the system accounts for the patient’s best interest. Just when you are at your weakest and least able to make all the phone calls, traverse the maze of insurance, and plead for health-care referrals is that one time when you have to your life may depend on it.’—Ross donaldson

In May 2020, Tejinder Singh was anxiously searching for a government health centre with hygienic facilities in Bathinda. The city has four urban healthcare centres (based out of Lal Singh Basti, Dhobiana Basti, Janta Nagar and Jogi Nagar) run by the Punjab government, but they seemed to be in a state of abject neglect, with significant staff shortages and inadequate infrastructure.2 Despite a target population of 40,000, and a prior multi-crore spend on constructing such centres, there was clearly insufficient spending on ensuring adequate staff and medical equipment.3 Such centres were witness to low utilization, given less staff and a lack of provision of appropriate medical services. Local doctors simply cited that the requirements had been shared with the state health department multiple times, and yet nothing was really done.

India’s healthcare system is heterogeneous in nature, with a variety of organizations offering healthcare services, ranging from individual providers to small groups to large corporates. There is significant variation in healthcare quality, particularly in an urban context, across states and union territories, and even within states. The healthcare delivery system is fragmented in nature, with no single infrastructure element that links all the providers—although the government is seeking to make a start at this with the national health ID card. Regulation at the centre and the state level, along with its cousin, governance, have been constraints on India’s healthcare system, giving rising to service delivery gaps. Over the past two decades, the liberalization of the Indian market has also led to a liberalization of the healthcare services market, leading to increased investment and a greater absorption of technological innovation. And yet, this has not been completely transformative. Instead, an odd hodgepodge exists, with run-down primary health centres (PHCs) existing with super-speciality private hospitals. Healthcare delivery is expanding across different segments, with certain players attracting the affluent, whereas others seeking to target the downtrodden. Many of the upcoming business models in healthcare delivery in India are increasingly world class, with much to offer in best practices; however, the large public healthcare system and its underlying delivery model, organization structure, governance and financing arrangements remain mostly unchanged since Independence. Meanwhile, as the private sector has grown, it has been dominated primarily by solo practices, notwithstanding the growth in the corporate subsegment; in this sector, paying consultation fees and premium charges for treatment, post-operative care and medicines is de rigueur. Given the fragmentation of the sector, provider performance is notoriously hard to measure. There are few, if any, linkages between the public and the private hospitals, with both sectors having productivity and efficiency issues. Health System for a New India: Building Blocks, Niti Aayog, November 2019, https://bit.ly/3G6JGcb. 5 Ultimately, ordinary Indian citizens have to fend for themselves, with high out of the pocket spending, and yet having potentially poor outcomes. Altering this will require a transformative change in the way India’s healthcare system operates. This change will not be a single model that fits every metro, town or village, but will require customization across the urban hierarchy. India has done well in recent years, putting down the building blocks for crafting a robust and universal healthcare system. Non-contributory government-sponsored health insurance schemes (for example, Pradhan Mantri Jan ArogyaYojana [PM-JAY]) have been expanded to cover over 500 million people (the government continues to expand these to cover other population segments). The National Health Mission (NHM) has invested ~$20 billion to bolster the public delivery system between 2005 and 2019. This has included the hiring and deployment of ~900,000 community health workers (colloquially known as Accredited Social Health Activists [ASHAs]). The government’s push for integrating the local system of medicine under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) has also expanded healthcare capacity.6 Such providers have been integrated into existing allopathic care practices.

The colonial experience

It’s not that India is starting from scratch on urban healthcare. While urban India has had local systems of medicine, with an informal system prevalent for centuries, western allopathic medicine in India can be dated back to the year 1600, with medical officers of the East India Company arriving in India as part of the first fleet.7 By 1764, a medical department in Bengal was established, with ~4 head surgeons, ~28 mates and eight assistant surgeons. This was expanded in 1785 to Bengal, Madras and Bombay presidencies, with a team of ~234 surgeons. By 1796, such hospital boards also started providing services to civilians and by 1857, a transfer of administration to the Crown had taken place. By 1868, separation of civilian and military medicine administration had taken place.8In terms of actual infrastructure, the first hospital was up in Madras (i.e., the Madras General Hospital) by 1679. Calcutta got a hospital (Presidency General Hospital) in 1796, followed by Calcutta Medical College in 1835, specializing in western medicine.9 By 1880, there were ~1,200 public hospitals and dispensaries in India, catering to 7.4 million patients. In the next two decades, by 1902, the number of hospitals and dispensaries doubled to ~2,500 (a hospital available every 330 sq. miles) catering to almost 22 million patients (a threefold increase).10From a mental health perspective, too, the colonial government did make an initial attempt, establishing lunatic asylums (for the mentally deranged) via an Act in 1858, with control given to the local civil surgeon in each district. About 4,600 patients, on an average, lived in such asylums from 1895 to 1900, with centralized asylums set up in Bengal, Bombay, United Provinces, Punjab and Madras. On the sanitation front, a royal commission was established in 1859 to report on sanitary conditions of the colonial army. Sanitary boards were also set up in each province in the same year. Sanitary commissioners took over these boards, conducting inspections, supervising vaccination campaigns, maintaining vital statistics and collecting meteorological data. By 1885, the local self-government act was passed, with local bodies coming into existence, which were responsible for sanitation at a local level. By 1912, the Government of India appointed deputy sanitary commissioners and health officers with such local bodies.Colonial India’s healthcare administration surprisingly did a fair bit on the public health side. With regards to disease control, despite population presenting a constraint even in colonial times, significant work was done to combat plague, leprosy, cholera and malaria. In addition to the 1812 plague outbreak in Kutch lasting over a decade, another outbreak was rumoured in Hisar district in Punjab in 1828 and 1929, and apparently an outbreak in Marwar state in Rajputana in 1836.The port city of Bombay had a bout of bubonic plague in 1896, which expanded to Pune, Calcutta and Karachi. Eventually, the plague took 2 million lives (estimated; the actual figure could be a multiple more) by 1903.11, 12Various measures were taken to combat this—the Plague Commission was established in 1896, with its report in 1904 highlighting that the disease was quite contagious, with human transit a key source for spreading the disease. A range of preventive measures were instituted to disinfect and evacuate infected places, along with a push for strengthening public health services and rollout of laboratories.13 Regulation quickly followed with the Epidemic Diseases Act (1897) and inoculations were organized on a large scale basis, using Haffkine’s Anti-Plague vaccine.Epidemics associated with cholera were frequent in British India, notably occurring between 1817 and 1821.14 A cholera committee was set up after the 1868 epidemic, which studied the origin, generation and transmission of the disease. This led to a push for improving sanitation, along with management of festivals and development of hygienic conditions in jails, cantonments and hospitals.15 A number of detailed studies were carried out which established the contagiousness of the disease, leading to the evolution of new treatment options and prevention methods.16, 17Malaria, a disease endemic to India, was always a leading cause of death in the country. However, the colonial expansion of the railways and irrigation canals, along with deforestation and construction in former swamplands, led to a rise in the prevalence of the disease. By 1840, due attention was given to ensuring proper drainage, along with the usage of quinine.18 The Indian Medical Service, under Sir Ronald Ross (as surgeon major), did exemplary work from 1881 onwards in demonstrating the life-cycle of the malarial parasite, leading to the establishment of malarial control programmes. Numerous studies were conducted on the prevalence of the disease in Indian provinces (for example, a survey of malaria and environs in Calcutta by M.O.T. Iyengar; a mosquito survey in Karachi by Dr K.S. Mhaskar in 1913).19, 20 Other diseases like kala-azar and beriberi were also studied, with a Sleeping Sickness Commission formed in 1910 to investigate enteric fever.21Other studies were conducted on yellow fever and hookworm disease as well, along with tuberculosis.22 It must be noted that the colonial design of medical services was quite euro-centric, particularly with regards to its priority patients (like the European colonialists), and was characterized by a neglect of the native population, along with no significant focus on research; however, the officers and researchers of IMS were able to study local disease and contribute significantly to limiting their spread.

On status of urban health care

Malti Yadav heaves a sigh of relief on having delivered her baby at the local district hospital—the situation could have been far worse without the support of the local attendant. Kushinagar’s district hospital has only one obstetrician and gynaecologist, who can cater to situations requiring a caesarean delivery. Ramya Tyagi, a specialist, who serves in the role of a gynaecologist in this hospital, was quite forthright in her views—she is here to serve her term, while being on the lookout for opportunities in the private sector. With her husband and children in Bhopal, over a day’s journey by train, this is not the ideal location where she would have wanted to build her career. When India gained independence, it made the setting up of large tertiary hospitals and medical colleges a priority over investing in primary healthcare centres. There was greater faith in technology-based disease control programmes, instead of a focus on general healthcare systems that operated at the village level. The All India Institute of Medical Sciences (AIIMS) was set up in Delhi in 1956, modelled after the John Hopkins Medical Centre in the United States (US).23, 24 The first PHC was set up only seven years after independence.25Even in 2011, the situation was still quite dismal. There were only 45,062 doctors26 available to serve the rural population. Between 1989 and 2000, ~54 per cent of all medical graduates from AIIMS migrated out of the country.

The IndIan MeTropolIs: deconsTrucTIng IndIa’s urban spaces240There has also been a limited focus on public health—we may have beaten polio by pushing for mass immunization, but we did nothing for its mode of transmission (for example, fecal–oral transmission via contaminated water supply).28 Investment in the application of medical technologies seems to have become a substitute for taking action on essential issues like nutrition and sanitation. Yet, India’s healthcare system is not all gloom and doom. There have been notable successes—there has been an elimination of a number of communicable diseases, like polio, guinea worm disease, neonatal tetanus, etc., in the last few decades. India’s Total Fertility Rate (TFR) has been significantly reduced to 2.27 births per women (in 2017),29 compared to 3.2 in 1992–93.30 Even at an overall level, the maternal mortality ratio target (as per the Millennium Development Goals) of 139 was met and was at 113 per 100,000 live births between 2016–18 as on July 2020 and further improved to 103 in 2017–19 as on March 2022.31, 32Best practices in public healthcare highlight that the burden of disease needs to be estimated on a regular basis, in order to conduct effective socio-economic analysis on key interventions. The World Health Organization (WHO), amongst others, has fostered a widely used methodology, called disability-adjusted life years (DALYs), which combines the impact of fatal and non-fatal events33, 34—this measure is now widely utilized in policy circles even in India. The Global Burden of Diseases (GBD), Injuries and Risk Factors Study Secretariat also conducts estimates of death and disability at a national level across developing countries.35Urban India has historically been characterized by variable patterns of morbidity, along with low levels of utilization by the urban poor living in slums and resettlement colonies. A study was carried out by the National Council of Applied Economic Research (NCAER) in April–July 2000, with a sample size of 2,000 poor and low-income households (~1000 each in Delhi and Chennai; with a skew towards slums compared to resettlement colonies). About 60 per cent of the sample set was from scheduled caste households in Chennai; Delhi had ~42.5 per cent.36 Generally speaking, residents of such slums and resettlement colonies were found to be better educated in Chennai than in Delhi; ~50 per cent of sample households in Delhi reported the head of the household being uneducated; the proportion in Chennai was ~30 per cent.37In terms of morbidity, generally speaking, slum population in urban areas tend to have a higher rate.38 This can be due to multiple reasons—health facilities may be particularly short for slum residents who have recently arrived. Additionally, those from low-income households may be more exposed to economic shocks associated with the onset of a disease, with their high dependence on labour-based income impacting earnings significantly. Additionally, for women, the challenges can be greater—there is usually lower awareness about the need for hygiene, while socially induced lower levels of education and associated stigma about women-related health issues may lead to significantly higher morbidity along with lower treatment rates.