Kerala goes to the polls on April 9. Amid the din of electioneering, one crisis has gone unnoticed: the threat of spiralling out-of-pocket health expenditure for millions of people in the state.
The reason is simple. Foreign equity firms are on an aggressive private hospital acquisition spree in the state.
For instance, KKR has acquired the Kozhikode-headquartered Baby Memorial Hospital and Meitra Hospital. Meanwhile, Blackstone-backed Quality Care has taken over KIMS Health in Thiruvananthapuram and Aster DM Healthcare. Both deals happened within the last two years.
With profit becoming the primary driver, health experts fear the consequences for ordinary patients could be severe. Yet not a single political party has made this an election issue.
"It should have been a huge election issue," admitted public health expert and former Kozhikode Medical College professor KP Aravindan. "People are not aware of the impact of private hospital takeovers."
Why foreign firms target Kerala?
Kerala tops in most of the healthcare indices in the country, because of awareness, access to quality healthcare and availability of disposable income. However, about 70 percent of the population depends on private healthcare facilities. Only the remaining 30 percent rely on government hospitals.
Of Kerala's 3.6 crore population, roughly 65 lakh (18 percent) are above 60 years. Apart from this, the state is grappling with increasing morbidity across all age groups.
Public health activist and former vice-chancellor of Kerala University, Dr B Ekbal said foreign firms eye Kerala because of its ageing population, morbidity rate and people's readiness to spend on healthcare.
"Breast cancer is common among middle-aged women. Most of our youngsters are obese. Contagious diseases are on the rise. There is a wide spectrum of morbidity in Kerala," Ekbal says.
According to him, high morbidity increases the potential of curative care.
"Keralites are ready to spend on healthcare. This has resulted in the setting up of private super speciality hospitals, which are subsequently being taken over by equity firms," he says.
Aravindan said the foreign firms are not essentially targeting the local population. He insisted that the big companies will not be able to survive in Kerala, if they are not aiming at tapping into medical tourism.
"Kerala is well positioned to become a medical tourism hub, for many reasons. It has well trained and efficient medical staff, better communication systems and infrastructure and ease of access from countries including the Gulf which might be the reasons these companies are interested in Kerala," he said.
Who is to blame?
Kerala Chief Minister Pinarayi Vijayan once criticised the takeovers, alleging that 'vested interests' have been working to weaken the public health sector. But neither he nor his party, the ruling Communist Party of India (Marxist), made the takeover an election issue.
The Congress too ignored the issue. When contacted, Congress leader and health expert Dr SS Lal shifted the blame on the state government.
"Health is a State subject. However, the health minister (Veena George) speaks as if private hospitals don't come under her authority. The Health Ministry is not limited to just government hospitals, it is the supreme authority covering the entire sector," he said.
But the CPM countered this by noting that the state government cannot directly regulate foreign investments.
"What we can do is to prepare alternatives to face the crisis. On that front, Kerala has one of the best healthcare systems in the world," said CPM leader Jaick C Thomas.
Dr KP Aravindan agreed that it is nearly impossible for the state to regulate private investments, especially when the central government has been encouraging foreign investments.
"The government should instead focus on providing better facilities in the public sector hospitals," he said.
When asked about the type of state regulation needed, Congress leader Lal cited the CPI(M)-led government's intervention to slash the price for Covid-19 tests.
"Such regulations can be implemented on a larger scale," he said.
Role of small hospitals
Out-of-pocket health expenditure is high in Kerala because of people's reliance on private speciality hospitals. This has decreased the number of doctor-led hospitals and other smaller clinics, which formed the backbone of rural healthcare progress in Kerala.
Ekbal said smaller hospitals started shutting down even before foreign companies entered the healthcare sector.
"Smaller hospitals are shutting down as people have become increasingly aware of different healthcare issues and medical check-ups. Even if it is a headache, most Keralites will go to a super speciality hospital and consult a neurologist. This culture has contributed to the crisis affecting smaller hospitals," Ekbal said.
However, the opposition believes some government policies are exacerbating the crisis for smaller hospitals.
"Small hospitals are getting subsumed by larger, super-specialty hospitals. Policy shifts like amendments to the Clinical Establishment Act are being pushed without measures to safeguard the smooth functioning of such hospitals," said Lal.
Aravindan also urged the government to fund and support smaller private hospitals to reduce the impact of the impending crisis.
It is high time political parties heeded these calls and moved beyond complacency, whataboutery, and blind criticism to take comprehensive steps to prevent Kerala’s impending healthcare crisis.