Without universal health coverage, World Health Day means little to most of India

How far will you go to save your child or parents? To poverty and beyond, is what many thousand Indians are doing each day. The draft National Health Policy 2015 mentioned that 63 million Indians face poverty due to health expenses every year. Millions more suffer grave financial losses. In an India where you and your sentiments matter only if you have a social media account, these people’s misfortunes simply remain inaudible and invisible.

A health system directly affects the financial condition of citizens through what is known as out-of-pocket expenses, or OOPE. This is the money patients pay right away from their own pockets (as against insurance or government-provided free care). In good health systems, out-of-pocket expenses are insubstantial. For instance, out-of-pocket expenses in Norway, UK, and France – which have robust national health systems – are 14%, 9% and 7% of their total health expenditure respectively. For India it is almost 60%.

Debt spiral

Today is World Health Day, and the theme this year is Beat Diabetes. To understand how high out-of-pocket expenses can be devastating, let us suppose there is an old man with diabetes who hurts himself in the foot and develops a wound. As is well known, diabetics should take no wound lightly – even a small injury can get severely infected and occasionally cause the part to be amputated, or even death by sepsis. Thus, for this grandfather and his family, it is a fairly serious incident.

Now, if they are citizens like those of us reading this article, they’ll mostly have some form of health insurance. They will also most certainly possess the financial capacity to visit a clinic, get the wound cleaned regularly, and consult an expert doctor for any change in the dosage of medications. The distance of the clinic from their home, or the cost of transportation, or the requirement to spend some hours at the doctor’s, will hardly cross the family’s mind. In a few days, for many such grandfathers, the wound will have healed and they will resume their normal routine.

Citizens like us, however, are among the fortunate few mostly working in the organised sector of India’s economy. We are not poor farmers, or construction workers, or housemaids, or sabziwallahs and chaiwallahs, or rickshaw-drivers. People in such professions (the unorganised sector) outnumber us several times over. Around 400 million working-age Indians (and their many million kids and aged dependents) live on whatever little money they can earn from such jobs. It is mentally stressful to even imagine what such a family might go through if a family member was in a similar situation.

The daily diabetes medicines must be already taking a heavy toll on the family, especially since they might have to buy them from a private pharmacy as the government’s often is out of stock or has ineffective drugs. Grandfather’s diabetes is still never under control as he frequently misses doses, or sufficient food, or both. To top that, he gets a wound on his foot.

Shameful situation

He will mostly ignore it – because either he doesn’t know it can get deadly (if his diabetes was treated by some affordable, under-qualified practitioner who didn’t counsel him properly), or he doesn’t have the heart to spend more of his kids’ money. Though government clinics offer free basic treatment, Indian citizens are so troubled by the poor quality of care, corruption, and callous attitudes of the staff, that they prefer private providers. Still, even if our grandfather didn’t mind visiting the sarkari clinic, he might find the distance and cost of transportation prohibitive (especially if he lives in a village); or he might be too old/weak to go by himself. Asking someone to accompany him will mean they will lose half a day’s worth of wages. Nonetheless, some kids will take grandfather to the clinic and he will most probably get well – but at a huge financial cost, as for them even a simple out-patient visit is actually quite expensive.

Others will just wash the wound at home – using no soap, and water which mostly is unclean and that too only if there’s enough available. If they’re lucky, the wound will gradually heal. If not (a more common scenario), the wound will get dirtier, larger, and more painful. Again depending upon each family’s limited paying and borrowing capacities, some grandfathers will be taken to the doctor at this point while others will still remain home, perhaps until the whole foot turns dark and unbearably painful. In either case, a hospital visit and more expenses are inevitable (often even in free government hospitals people have to pay for miscellaneous costs). The family will have to either borrow money at high interest (sometimes by mortgaging land), or use up their modest savings, or sell land or other assets.

This way, several families end up deep in debt. Most already have some other debt. With the kind of income they earn and its unpredictability, it is impossible for most of them to ever recover fully from this financial shock – something known as “catastrophic health expenditure”. Despite the expenses, many grandfathers, with their infection so advanced, either are permanently disabled (adding more to future costs of care), or die from sepsis. All because of some sugar in the blood, a wound on the foot, and no money in hand.

The more one thinks of it, the more it's clear how painful and shameful the out-of-pocket expenses situation in our country is. While this was a hypothetical example, journalist P Sainath wrote about the grim real lives of Maharashtra farmers and their out-of-pocket expenses woes 11 years ago, in a report titled: Health as someone else’s wealth. Today on World Health Day, in the 69th year of our Independence, we need to wake up to the persistent presence of this national shame, and realise the urgent need for universal health coverage.

According to the World Health Organisation, universal health coverage is when “all people obtain the health services they need without suffering financial hardship when paying for them”. Our national and state governments need to shun the usual political lip service and implement such coverage. In fact India did have a vision of universal health coverage in the past (with its extensive network of subsidised government health centres), but lost track somewhere. In recent decades, politicians have contended that fancy insurance schemes are the answer to impoverishing healthcare, but that’s an incorrect belief. There exists a whole gamut of scientific research to guide future efforts, including the report of the High-Level Expert Group on universal health coverage and the recent Lancet report – Assuring Health Coverage for All in India. The only thing now needed is political will.