Death or debt is the question

People are poor because they have ill-health

In 2015, I chaired, at the invitation of an international non-governmental organisation, a round table of a dozen members of Parliament, together with other policy-makers and civil society activists, to address a burning question: why wasn’t public health more of a priority for our political class? The discussion was rich and illuminating, but one fact stood out for me: that every single politician present agreed that public health simply wasn’t an issue that any voter bothered to press them on. When they visited their constituencies, MPs were badgered on a number of other issues, but no one told them to vote for, or spend more money on, public health. That’s why it didn’t loom large in their consciousness.

If any one thing has changed in our voters’ minds in the aftermath of the pandemic, it should surely be this: the public is now much more aware of the importance of health, and of the need for adequate governmental and political attention to it. This is true of the medical landscape across the world, where the Brookings Institute suggests that a $4.4 trillion increase in spending on public health care, especially among developing countries, is likely by 2040. Of course, these numbers alone will count for little if we do not leverage the current global momentum to address the principal challenges facing the health care ecosystem in our country. Key among these are the immediate and everyday challenge of the difficulty Indians experience in obtaining access to affordable quality health care. Affordability is the key issue here. Take Kerala: a state with perhaps India’s best health care system, with a doctor to patient ratio of 1:400, far better than the WHO standard of 1:1,000 and the Indian average of 1:2,000 people. Yet, in Kerala, since the 1990s, private health care has vastly surpassed the public health care infrastructure, with one estimate showing that 95.31 per cent of the hospitals and 97.09 per cent of the dispensaries in the state are run by private organisations. Even among poorer households, the majority currently prefer to look to private options for health care given the perception that the quality of treatment and facilities available at these venues are better. But this raises the ominous challenge of ruinous out-of-pocket expenditure to finance medical treatment.

Shutterstock Shutterstock

Poverty remains one of the biggest challenges for India. But there is less awareness of the enormous role that health care plays in deciding the fate of India’s poor. The working poor are one economic shock—which, for a daily wage labourer, could mean as little as missing a single day’s work and pay on account of illness—away from slipping below the poverty line. A terminal illness like cancer could mean wiping out a family’s economic security, as land and home are sold to meet the medical expenses of the principal breadwinner when he is no longer able to earn to support his family. About 47 per cent of hospital admissions in rural India and 31 per cent in urban India are financed by loans and sale of assets, among the worst in the world. People often don’t have ill-health because they are poor; they are poor because they have ill-health.

So it is not enough just to give public health care a greater priority in governmental policy-making. Despite all the positive efforts to make quality health care accessible in Kerala, we are home to one of India’s highest levels of out-of-pocket expenditure. A 2020 study, which surveyed the impact of OOP expenditure in rural Kerala, found that 41.6 per cent of the total income of study participants was spent for health care of chronic diseases, which indicates a catastrophic level of health expenditure. This has worrying implications for the ability of our more vulnerable segments to stay afloat after medical expenses, and should be a concern for policymakers. So more resources for government hospitals and primary health facilities, and universal government-backed medical insurance to support continuing costs, are vital. Disease should not mean choosing between death and debt for so many of our compatriots.