Public vs. Private Hospitals in India
Dr. K. Aditya, a 29-year-old on the last day of his three-year residency at Osmania General Hospital, has been on duty for the last 36 hours straight, adjusting the anesthetic levels of neurosurgery patients. Today marks the end of his studies at one of the most grueling medical schools in India, Osmania Medical College. But instead of celebrating with a valedictory nap, he meets me in a lounge behind the neurosurgery OR and launches into a speech on the subject which has consumed him and many of his fellow students for the past decade: how to restore Hyderabad’s faith in its public hospitals.
Hyderabad is a city of contrasts. A room in the luxurious Nizam’s Taj Falaknuma Palace hotel sells for $440 a night, almost as much as the average resident earns in a year. Mansions and slums rub elbows in the Jubilee Hills neighborhood, while Jaguars jockey for space with auto-rickshaws on the crowded city streets. Perhaps the greatest contrast, however, is that between the public and private hospitals.
Between 2000 and 2006, the state government’s expenditure on healthcare fell from 5 percent of the budget to a meager 3.5 percent, averaging less than three dollars per person. Meanwhile, more money is spent on private healthcare in Andhra Pradesh than anywhere else in the nation. Government hospitals were caught between the hammer and the anvil: on the one hand the budget cuts, on the other glamorous private hospitals which run ad campaigns to draw away their patients.
The budget cuts have taken a heavy toll. The only CT scanner in Osmania Hospital is a relic from the 1980s, and is frequently broken. A new one was purchased last month, but sits in storage unopened because there are no rooms available for it.
Enterprising businessmen have built pharmacies in the courtyard of Osmania and now run a lucrative business selling pills. According to the hospital administration, however, the customers who buy these pills don’t exist. “Care at this hospital is provided absolutely free,” says C.G. Raghuram, chief anaesthetologist. “Health is the birthright of every person who walks through that door.”
Mohammed Shafir, who runs the Vishnavi Medical and General Store outside the Osmania out-patient building says he sells basic drugs like amoxicillin to over 250 patients a day. As I spoke to Mohammed, a teenaged beggar holding a battered Xray shuffled up to me, asking for money to buy medicine.
The lack of equipment, drugs, and staff takes its toll on public opinion. “People just lost faith in the public hospitals,” says Dr. Aditya. Many choose the alternative of private care, despite the price tag. By 2003, nearly 65 percent of the poorest families were forced to borrow to pay their medical bills. The catastrophic debt drove many farmers to suicide. In the years since, despite various health insurance programs, healthcare debt continues to drag families below the poverty line.
This was the atmosphere which surrounded Aditya and his colleagues, the best and brightest of Andhra Pradesh’s medical students, as they started their schooling at the state-run Osmania Medical College. They could have accepted the decline of the public sector. After all, an Osmania diploma could earn them a job at any of the prestigious private hospitals in the city; they weren’t stuck in a career at a government hospital.
But the Osmania students refused to accept the death of Hyderabad’s public hospitals. In 2010, they partnered with other colleges and mobilized their union, the Junior Doctors’ Association (JuDA), to lobby the state government for better infrastructure at Osmania and nine other large teaching hospitals in the state.
Three years later, his residency finished and a career at the Care Banjara Hospital ahead, Dr. Aditya is still busy lobbying the Minister of Health, planning strikes, and filing cases in the High Court to protest the government’s neglect of the public hospitals. “If we join hands,” he says, “we can save this system.”
A Tough Apprenticeship
“It’s painful to see someone dying in front of your eyes,” says Dr. Aditya, “You know what to do, what you’re there to do, but you don’t have the equipment to do it.…Being a doctor here is a Herculean task….They’re forcing us, pushing us to the wall, just because we’re students.”
After finishing their post-graduate studies at Osmania Medical College, students are required to complete a three-year “residency” at government hospitals, one year of which is spent at one of the Primary Health Centers (PHC) in rural Andhra Pradesh, small clinics which provide basic care and referrals to villagers.
Theirs is a residency in only a technical sense since the work at PHCs requires them to do whatever job happens to be necessary, regardless of specialization. One junior doctor, an opthamologist, was required to deliver a baby at the PHC, without any of the requisite knowledge or training.
While working in the rural Primary Health Centers, once the cornerstone of preventative medicine in India, junior doctors have too little equipment to perform even the most basic procedures. One clinic in Ambatpally, a poor village 70 miles south of Hyderabad, was supposed to serve over 20,000 villagers from the surrounding area, without access even to hypodermic needles. Patients were asked to bring their own.
Doctors are assigned to these PHCs, says K. Aditya, so that politicians can claim they care about the rural population. But a doctor can’t save lives with his bare hands. He needs equipment—equipment the state is unwilling to supply.
These doctors, fresh from med school, have limited options: either they can sit in the PHC with their hands tied by the lack of equipment, or they can swallow their idealism and bribe their supervisor so that they don’t have to come to work at all. Most choose the latter option. “It’s almost like it would be a relief for them if we didn’t come to work,” says G. Aditya, a friend and fellow JuDA member with K. Aditya. As long as government statistics say there is one doctor at every PHC, and as long as voters buy it, the politicians are content. Whether or not medical care actually reaches the poor is a moot point.
Their residency at the government hospitals in the city is equally disheartening. Working long hours, the junior doctors experience all the shortcomings of Osmania Hospital, from power cuts, to lack of drugs, to the shortage of functioning equipment. “One of the operating tables collapsed during a procedure,” says K. Aditya, “We propped it up and finished the operation. It hasn’t been replaced.”
Jerry-rigged operating tables are not what their textbooks led them to expect. “It’s impossible to do things by the book here,” says Aditya. “The equipment here forces us to treat patients in a way which is unethical.”
Since they do the bulk of the work in Osmania hospital, junior doctors also face the most attacks, verbal and physical, by angry family members who think their loved ones have died because of their negligence. The myth of the easy, luxurious life of corrupt doctors—popularized in Bollywood star Amir Khan’s 2013 documentary on the subject—doesn’t help. “Emotions run high,” says G. Aditya. “I’ve been intubating a difficult patient, and when I look up I see that I’m surrounded by a crowd of angry family members. I know that if I screw up they’ll beat me up….My friends have been attacked.”
Aditya and his coworkers at Osmania often work 36-hour shifts, without access to basic medications, equipment, and assistant staff. In the entire 1,400 bed hospital, only a handful of nurses were on duty the night of my visit, one for every two wards. On my tour through the post-op wards, I saw only about three pulse oxymeters per 20 beds, and fewer ventilators. The cabinet of medications in the post-op neurosurgery ward lacked basic drugs used to stimulate heart rate in critically ill patients.
Aditya led my tour through the wards, pointing out new curtains and AC units which had been purchased to impress the health minister during one of his rare tours. One waiting room, like a ghost town, had been built and furnished solely for this visit, and was now unlighted and unused, waiting to be boarded up. When asked why politicians didn’t visit more frequently, he said, “Politicians don’t have the guts to come here. They know that no matter how much security they have around them, they’ll have to answer questions.”
After Aditya’s angry accusations, it was shocking to see the calm resignation of the senior doctors at Osmania. I met with Dr. Jafar Hashmi, the director of the Aarogyasri Insurance Program at Osmania, who gave a fatherly lecture on the vagaries of the Indian medical system: “The healthcare system here is an intricate mechanism,” he said. “You can’t judge it by a Western standard…everything, even simple repairs, has to go through a long bureaucratic process.”
When I asked him about Dr. Aditya’s frustration, he simply said that the administration sees the real complexity of the situation, while junior doctors oversimplify things.
And the junior doctors’ strike in protest of the lack of infrastructure?
“Those strikes are one of the reasons for the inefficiency in this hospital,” he said. “Sometimes, I think we have more democracy in this country than is good for us.”
K. Aditya claims that this complexity that Dr. Hashmi points out is simply an excuse, evidence of the government covering its back for its failure to make the public health sector work. Meanwhile, the state pours 25 percent of its healthcare budget into public insurance schemes that cover only curative care: lucrative for private hospitals, but ineffective for the everyday sicknesses of the common man.
When told Dr. Hashmi’s point that government hospitals simply can’t deal with the huge number of patients, that it’s necessary to invest in a health insurance scheme to send those patients to private hospitals, Aditya exploded:
“Bulls—. Just build more public hospitals!”
The same message, in slightly different phrasing, was the consensus of the Bhore Committee, formed in 1946 to plan the health system of the newborn Indian nation. “There was a general agreement, among those whom we interviewed, that prohibition of private practice was essential in order to ensure that the poor man in the rural areas received equal attention with his richer neighbor,” the Committee reported.
“We consider, therefore, this for the present medical service should be free to all without distinction and that the contribution from those who can afford to pay should be through the channel of general and local taxation.”
The Bhore Committee Report, once the Bible of the Indian public healthcare system, has fallen by the wayside as private hospitals take over the patient load from the public sector, often with the help of government land grants and insurance programs. This week, the government will outsource care of its own employees to private hospitals. “When government is shifting people to corporate hospitals for treatment,” said Aditya, shaking his head, “what do you think it symbolizes?”
The JuDA has tried to fight this trend, but it has limited weapons in its arsenal. Its members have pooled what little money is left over from their monthly stipends to hire a lawyer and have filed a case in the High Court against the state government. They argue that the required rural service is unconstitutional unless the PHCs are adequately equipped. So far, the case is stuck in court. They have also tried to arrange a committee to discuss issues of funding with the Directorate of Medical Education, but without result.
The last weapon in their arsenal is controversial, dangerous, and (some claim) a violation of the Emergency Services Maintenance Act.
It is going on strike.
In January this year, as the government refused to hear their requests for improved medical facilities in Osmania General Hospital and nine other teaching hospitals in the state, hundreds of junior doctors went on a 44-day strike.
The first result was a storm of negative press: “Eight Die as Emergency Services Crippled in Andhra Hospital,” was the headline of an article on ndtv.com, which went on to blame the deaths on the junior doctors’ strike. “We gave 72 hours warning to the government,” says Dr. K. Aditya of the strike, “But they refused to listen. What else can we do? We have brought cases to the High Court, tried to meet the ministers, but they refuse to see us.” He flatly denied that any patients had died as a result of the strike. “Patients die preventable deaths every day because of the lack of equipment, but when they happen to die during a strike we are always to blame.”
“Immediate measures should be contemplated to strengthen and create a functional Emergency Medicine Department…” So begins a formal agreement between the Government of AP and the JuDA signed February 2013, which signaled the end of the strike. The government had passed similar formal agreements several times before, but this time many of the young doctors hoped it indicated a change in the government’s policy toward public hospitals. But half a year has passed, and the emergency medicine department is as dysfunctional as ever. With a government that has refused to honor its promises, Dr. Aditya says, “the younger generation is becoming disillusioned with the system.”
Apart from the agreements on paper, there is little tangible evidence of the struggle junior doctors have waged against the state. Dr. Aditya has had a few small triumphs: grates on the windows (“to keep out the monkeys”) and a renovated ICU (“I had to pester the administration for years to get this”), but the core problems of the public hospital remain unsolved.
But Aditya hasn’t lost hope, and is in the process of passing the torch to the next generation. “Is there going to be another strike?” whispered one young doctor as we walked through the Neurosurgery Ward. “Maybe,” he said, “But that’s your guys’ responsibility now.”
Jon Cox is a Pulitzer Center Student Fellow from Davidson College. Photo Courtesy Subject.