Mainstream WeeklyWhen Ramani Atkuri walked into a primary health centre in a tribal pocket of Jhabua in Madhya Pradesh, there was no one in the registration centre or the consultation room. Surprisingly, the simple rural folk gathered there were not upset. A young man was, however, busy dispensing medicines at the pharmacy. Atkuri was surprised when he ran to the registration counter after a while; five registrations later, he hurried to the consultation room and took his seat. Yes, the young man was a junior doctor doing multi-tasking. All other key posts were vacant because no one wanted to be located in a remote area.
Welcome to India’s badly creaking health sector. Jhabua is far removed from the glitz of private hospitals in cities and India’s much touted ‘health tourism’. But Jhabua is no isolated example; it is just that the government-run medical hub represented everything wrong with India’s health ecosystem.
The young doctor at Jhabua had no one to consult. No doubt sincere, he prescribed varying combinations of medicines regardless of the patients’ condition, hoping for the best. He seemed unaware that incorrect or unnecessary medication of anti-biotics could cause harm. He had received no training in public health or primary care either. He was doing a job unlike many others who would either go on leave or refuse to join if shunted to remote or inaccessible areas.
As someone who has won accolades for her work in some of the most backward regions in the country, Atkuri, a doctor in community medicine, says India is one of the most unequal societies globally today. The brazen inequities in health reflect this. A country which can launch a mission to Mars cannot spend even 2 per cent of its GDP on health.
The result? Miserably poor investment in healthcare, manpower shortage, policy decisions divorced from ground reality, inadequate infrastructure, poorly motivated staff and miserable quality of data have combined to leave the most vulnerable sections of Indian society without access to basic health facilities.
This deadly combination, Atkuri says in her eye-opener of a book, Staying Alive: Dispatches from the Margins (Pan Macmillan), has resulted in a high rate of illnesses in India’s rural landscape. Rural patients are often in a more serious condition than their urban counterparts, flying against widely-held urban notion that villagers lead to naturally good health. Rampant malnutrition – a result of acute poverty – causes infections to become deadlier and more aggressive. And only a small percentage of them make it to a hospital in the district capitals.
Most Indians may not even be aware how health failures can improvise many of the poor. A study by the Public Health Foundation of India found that annually 55 million Indians are pushed below the poverty line due to healthcare costs. Indeed, costs of treatment, including for consultation, investigations, medicines and procedures, often force the poor not to approach doctors at all.
And if and when the poor do reach out to government-run medical centres, they are often met with indifference, rudeness and lack of medicines or equipment or both. It is not Atkuri’s case that all medical personnel are uncivil or inefficient. On the contrary, she praises doctors and non-medical personnel for doing a great job against tremendous odds, when they can. There are also numerous non-profit groups who serve the deprived on the medical front most diligently. The principal failure lies with the government’s inability to raise investment in healthcare.
As someone who was with the UNICEF for a decade before working among the disadvantaged in Odisha, Madhya Pradesh and Chhattisgarh, Atkuri warns that empanelling private hospitals for healthcare provision through insurance neither improves utilization of services nor quality of care nor protects against catastrophic health expenditure, especially given the poor regulation of the private institutions. Many Indians have learnt this truth the hard way.
It is revealing to learn that although hypertension and diabetes are dubbed “lifestyle diseases” and normally associated with those in towns and cities, they are common in villages too. The diabetes found among the poorest is recognized as Type 5 diabetes and is linked to malnutrition in early life.
In the process, India has a double burden of disease – increasing non-communicable diseases such as cancers, BP, diabetes and heart ailments, and also communicable diseases like diarrhoea or TB. Both cause massive fatalities. Even malaria hits the poor with a vengeance. While anyone can become infected after a mosquito sting, death is more common among those with low incomes. Similarly, TB is a disease of poverty and deprivation.
India boasts of some 200 million migrants – this is almost ten times the population of Australia! The normally battered migrant labourers, who go where work is available, are among the worst affected when it comes to healthcare. The lack of Aadhaar card in the place they work prevents them from accessing government services. Most cities, Atkuri says, lack a cohesive strategy to address the needs of their large migrant populations and often do not prioritize them in providing health services. Their suffering was most visible during the Covid crisis when hundreds of thousands walked and walked, often dying on the way. Their deaths went dominantly unrecorded.
A group of teachers who went to a school in a tribal part in Chhattisgarh to talk about nutrition were taken aback to find many students stunted and underweight. Many had only black tea and a piece of dry toast for breakfast; most did not bring lunch to school, making to do with a guava, a handful of roasted chana or nothing at all. The students admitted they could not focus on studies due to hunger.
It is this poverty which makes India’s wobbly healthcare scenario – five-star hospitals on the one side and lack of basic medicines and facilities on the other – so cruel, so inhuman. What many Indians take for granted is an unattainable luxury for millions. Under-nutrition is highly prevalent in India even as obesity is becoming widespread – the perfect example of a grossly unequal society. And Scheduled Tribes, except in India’s northeast and a few other pockets, experience the highest burden of under-nutrition. Childhood malnutrition is the underlying cause in nearly 60 per cent of deaths among kids under five years of age.
With her wealth of experience and exposure to raw poverty, Atkuri connects many other factors to the state of poor healthcare. The way the government treats creche workers volunteers is one. The lack of public transport in large parts of rural areas, particularly in northern, central and eastern India, is another. (BJP-ruled Chhattisgarh, Madhya Pradesh and Jharkhand have no state road transport,) At the same time, she praises health staff who live and work battling lack of equipment, enough medicines and secure housing. She also regrets incidents of violence against doctors and nurses by relatives of patients.
On top of all this, rampant digitalization has caused more problems in areas with poor Internet connectivity. This, along with frequent server crashes and failed facial scan, results in denial of even rations to eligible beneficiaries. The poorest again suffer the most. “Digitization does not inherently lead to more efficient or equitable services,” the author says.