CHENNAI: Talk to any doctor these days, and it’s likely that attacks and aggression against healthcare personnel by patients and their relatives is something of a sore point with him or her.
The home page of the website of Medicos Legal Action Group (MLAG), a lobby for doctors, asks in bold type, ‘Is India at war with its doctors?’ The author of the article, Dr Neeraj Nagpal, opens with a plaintive submission: “Having been in clinical practice for 28 years, I have had the opportunity to witness the ‘glory days’ of medicine when a patient with a normal gall bladder was operated erroneously but would still touch the surgeon’s feet.”
It goes on to cite the findings of an unspecified study that “one in four MBBS, MD, DM, MCh doctors have faced allegations of medical negligence in courts and consumer forums. Eighty-eight per cent MBBS and specialist doctors have faced anger or violence of patients or relatives in their professional career at least once.”
Another study frequently cited in doctors’ lobby literature in India is a survey by the Indian Medical Association (IMA) which claims to have found that nearly 75 per cent of doctors in India have faced some form of violence or threat of violence at some point in their careers.
In several states, doctors have frequently gone on strike demanding stringent punishments for those who attack doctors. Others have written articles highlighting the need for better security and surveillance at hospitals. Most of them blame “ignorance” and “the mob mentality” on the part of patients and their relatives for the attacks on doctors.
Studies of this phenomenon by medical professionals have found several causes and triggers for the public turning their ire on doctors. These include poor conditions at public hospitals, poor communication between doctors and patients, lack of faith in the judicial process, rising cost of healthcare and so forth. Among all of the reasons fuelling anger against doctors, the one that needs further examination is the cost of healthcare. Is the steeply rising cost of healthcare fuelling patient ire at doctors, paramedical staff, and hospitals?
Hospitalisation costs up 300%
India accounts for over half of the estimated 100 million people pushed into poverty worldwide every year due to high out-of-pocket expenses on healthcare, a joint report on universal health coverage by the World Health Organisation and the World Bank has revealed.
The document — Tracking Universal Health Coverage: 2017 Global Monitoring Report — published in the Lancet Global Health shows that currently, 800 million people spend at least 10 per cent of their household budget on health expenses for themselves, a sick child or another family member. For around 9.7 crore people, of whom over 4.9 crores are in India, these expenses are high enough to push them into extreme poverty, forcing them to survive on just $1.90 (Rs 122) or less a day.
In fact, healthcare costs have been soaring at an alarming rate in India. The 2014 report by the National Sample Survey Organisation (NSSO) shows that the average cost of hospitalisation in private hospitals has more than tripled since 2004. A bout of hospitalisation in urban India may have cost you Rs 8,850 on average in 2004. Today, it would cost you Rs 26,455. That’s a 300 per cent spike. This is a distressing fact in a country where the annual income of an average family is less than Rs 40,000. Further, the NSSO data clearly points out the fact that a large majority of India’s population is not covered by health insurance. “Over 85 per cent of Indians in rural areas and 82 per cent of urban residents have no health expenditure support,” the 2014 report noted.
As a result, out-of-pocket spending accounts for as much as 70 per cent of the medical expenditure incurred by a family. India’s neighbours are far better off on this count. In China, such spending accounts for 38 per cent of medical billing. In Pakistan, it is 41 per cent.
16% suicides triggered by illness
Faced with huge medical bills, many families turn to private creditors, who charge exorbitant interest rates and end up in a debt trap. According to the National Crime Records Bureau (NCRB), of the 1.3 lakh people who committed suicide in India in 2015, 16 per cent, or 20,000, did so due to illness. A large number of them do so because they couldn’t afford the cost of treatment.
“Even though the costs of all medical procedures in India are many times lower than those in western countries, they are sufficiently high to cause many families to go into debt and slip below the poverty line,” said Dr. Neeraj Nagpal of MLAG in a paper published in the National Medical Journal of India. Due to falling investment in public hospitals, the average Indian is left without access to affordable healthcare. There is only one government allopathic doctor for every 10,189 people in India and just one public hospital for every 90,340 people. More than 90 per cent of India’s allopathic doctors work in the private sector. Understaffed government hospitals frequently turn away patients or refer them to private hospitals. Adding to the burden, more people are seeking healthcare services in India today than a few years or a decade ago. For instance, in the 2004 report of NSSO, 33 out every 1000 people surveyed reported having been hospitalised at least once during the past one-year period. In 2014, that figure rose to 44. Profit motive in healthcare
As a result, a large majority of people are left to knock on the doors of private healthcare providers. The NSSO data show that private hospitals provide 79 per cent of all medical treatment in urban India and 71 per cent in rural India. This is despite the fact that the cost of treatment at private hospitals is nearly five times more than in public hospitals.
Since private hospitals are profit-driven, this often results in the tendency to prescribe unnecessary or irrelevant medical procedures. An investigation by Reuters revealed that many doctors in India routinely prescribe tests that are not relevant or needed. The news agency quoted Dr Arun Gadre, a doctor-turned health activist, who interviewed 78 doctors in India on medical malpractices. Gadre found that doctors sometimes order blood tests “despite not suspecting any health problems”. He also found that it is a common practice among doctors to accept bribes in the form of money, gifts or expensive vacations abroad from pharmaceutical companies in return for prescribing drugs manufactured by them.
Got a minute, doc?
Also, the perception that private hospitals are profit-driven results in patient disenchantment with doctors and the service they provide. Since the doctor is the primary interface between the patient and hospital, doctors are often at the receiving end of the ire of patients and their caretakers.
A 2006 study in the Indian Journal of Medical Ethics noted that patients are often angry about “constant demands by hospital authorities to pay for services.”
Further, in a bid to increase profits, private hospitals press doctors to attend to more patients than they have the time for. This shortens the amount of time a doctor spends with each patient. According to a recent study in the British Journal of Medicine (BMJ), Indian doctors spend less than two minutes seeing a patient. In contrast, in Sweden, doctors spend as much as 22.5 minutes per patient. In the US, a patient gets 21 minutes of a doctor’s time.
Doctors engaged by profit-driven hospitals are forced to see more patients because they are under “tremendous pressure to reach a certain target number of patients,” according to a 2013 report in Lancet.
Also, the same report noted that doctors in primary health care centres are paid large sums of money as kickbacks for referring patients to a specialty clinic.
Given these trends in healthcare, it’s no wonder that the crowd of patients in the tertiary medical sector is growing while it is thinning in the primary sector.