Do West Bengal and other provinces in India need reforming for a poor-friendly, safe, quality, and effective healthcare system instead of a health industry, public-private partnership, or health tourism for the rich and middle class society of the state or country?

Full Text

Have we made any progress in improving our healthcare structure in West Bengal? If not, why not? and how can we do better? It is certainly not better than it was in the 1980’s that is 33 years back in West Bengal. Rather what the author feels is that health in West Bengal, India, gradually became a Marasmus boy, just like the West Bengal Medical Education Services [WBMES] became marasmic,without its proper implementation since the last two decades, as the then left government was probably attempting to shake off responsibility from the welfare state-controlled free health and free primary & secondary education, through a privatization model for a Public-Private Partnership [PPP] model, and trying to establish a dangerous concept of health as health industry or health tourism, not only in tertiary care hospitals, and teaching institutes in the Metropolis of West Bengal, but also in some Primary Care Hospitals (64 in numbers), rural hospitals, and state General Hospitals, in huge profitable disciplines like Pathology, Microbiology, Radiology, Biochemistry and other diagnostic services nephro dialysis.

An effective health system of any state or any country must have sufficient service and resource people to deliver health care to its people, for which it is responsible, mainly for the unprivileged classes of society. It has been proved that socioeconomically disadvantaged men, women, and children have higher mortality and morbidity rates than persons of a higher socioeconomic status. Therefore, according to the author, there remains a tremendous need for developing an effective, but poor-friendly health system infrastructure in the state of West Bengal, in India, and also in other developing countries. One important key component for developing such a health system are the actions of health planning advisors of the state, India, which must take place in a community, which will have an impact on health, which is now almost lacking in West Bengal’s Health Services [WBHS]. The World Health Organization’s (WHO) definition of a health system includes all activities whose primary purpose is to promote, restore, or maintain health community participation in activities that improve the health and happiness of individuals and families. Engaging a local community to participate in identifying their own health priorities spurs the development of an innovatory, and culturally acceptable solution, which the author personally opines. The main feature of health care in West Bengal, India, according to the author, is a completely out-of-pocket payment system, that is, cost of personal health services are paid up by patients or keen parties, mainly in private sectors health care institutions (hospitals and nursing homes) and when large sections of the population remain uninsured for health care here. West Bengal, for the last decades has experienced a massive and mushrooming growth of private/or corporate care health provisions [are they fit for using terminology such as Hospitals’ as per the definition of WHO for hospitals at all, and also Research institute’? For such terminology who cares? The terminology “Research institute” they often uses to avoid many kinds of taxes to government ] licensed by the State Government Health Department, without proper and strict vigilance from the Health Department with regard to their profit, billing type, patient safety measures, quality health care, malpractice , doctor fees, quality of doctors round the clock, unnecessary investigations, putting even ankle fracture patients in the Intensive Care Unit (ICU), Intensive therapy Unit (ITU), Respiratory Care Unit (RCU), Neonatal Care Unit (NCU), and so on, and causes of death there from hospital acquired septicaemias, and thus competing with the existing rudimentary health care system in the open market capital economy, despite high involvement of the public sector in health services. Scientific, rational treatment even today occurs in West Bengal, but it is by the public care health providers. However, government spending funds in health care has decreased gradually, year after year, under the last left government. Growth of healthcare expenditure from pay-out-of- pocket system in West Bengal state today has outstripped the growth of expenditure for all goods and other services, and healthcare expenditure here has increased catastrophically due to private health care invasion in the system.

Such an explosion of healthcare expenditure in the state is due to*,1) the primary driver technological progress, for example, newer diagnostic tests, newer therapy applications,2) application of highly expensive patented molecules,3)as also, aging of population, the increasing number of population with chronic illness requiring long-term care,4) many more corporate-run trading hospitals and nursing homes, as well as, an attempt to privatize the public health care system, including opening of private medical colleges in the metropolis.5) Health is turning into a profitable industry, without any human face or touch to it, 6) with the entry of more private enterprises in the public health system, as PPP models, particularly in investigation services (Laboratory, Pathology, Imaging, and in Super Specialty subjects),7) due to the flow of sophisticated computerized medical gazettes for investigations, 8) rise in costs of drugs,9) irrational practices, irrational drug and investigation prescriptions by a certain group of doctors / specialists of the state [there is no prescription audit system or electronic data recording access by patients], and lastly due to a misguided priority setting in our health system. Today, priorities are set for the upper middle and rich class sections of this state), which results in false incentives in medical practice. There exist enormous gaps between the amount of money spent on health, and often patients derive much less benefit from it. Health care in the mushrooming private health care systems is often provided by low or very averagely talented (or often with foreign diplomas unrecognized by the Medical Council of India ,MCI) students or house staff, who have often been unsuccessful in state level Public Service Commission(PSC), Union Public Service Commission (UPSC), or other recruitment procedures [written and interview], and newly passed out postgraduates, post doctoral degree holding healthcare providers, without the expected long-term experience, who join these centres, for the very high lucrative salaries, perks, and various incentives they offer, compared to government services, which is a few lakhs. Thus, private healthcare business institutes remain the gainers in recruiting their human resources [although often of low quality] compared to public hospitals, without spending a single coin for their teaching, or training. Thus, there is loss and dearth of services to the government, in terms of money, labor, sweat, knowledge, and technology, which are provided by all West Bengal Medical Education Service (WBMES) teachers, to bring out the finished product successfully Post graduate trainees(PGTs) or Post Doctoral trainees (PDTs) to the accrued respective degrees, as specialists or super specialists in the market of healthcare. There remains a marked reluctance [even non-existence] to provide facilities to even the poorer sections of the society of West Bengal, in private health care sectors, although 20 to 40% of the beds and Outpatient Department (OPD) treatment must be provided free in those hospitals, but this remains as paper agreement between the private care hospitals and government, to have their trade and health license from the Health Department and their renewal . Who cares? There is no effective vigilance by the government in those trade houses. The out-of-pocket payment culture is now an important means of financing the health system in West Bengal and in the rest of India. Large and unpredictable health payment bills in the private/corporate institutions [these are five-star hotel suites rather] can expose poor households to substantial financial risks, and at their most extreme, resulting in improvishment. The house hold that sells its assets or incurs debts to pay healthcare bills results in a further rise in their poverty. The out-of-pocket payments for healthcare in corporate or PPP models, and also in public hospitals, are medical fees, bed charges [in private and PPP], room charges [air-conditioned; non air-conditioned], unnecessary ICU or ITU, NCU, RCU charges [in corporate sectors]; user charges to public care, purchase of medicine (whether prescribed or not), insurance copayments, excessive payments for appliances like pacemaker, angioplasty, angiography, coronary artery bypass graft (CABG) stents, drug eluting cardiac stents (including in public care hospitals, through company representatives), orthopedic appliances, diagnostics tests, commissions to large sections of clinicians from companies, diagnostics, radiology and imaging private laboratories, to computed tomography (CT) or magnetic resonance imaging (MRI) centers for referring patients, and ambulance charges. Establishment of user fees, since the 1990s, in public hospitals, showed evidences of a decrease in uptake of health services by the poor. Some of author’s cardiologist friends in the Institute of Cardiovascular Sciences – Institute of Post Graduate Medical Education and Research (IPGMER). Kolkata 20, told him in a table discussion that the result of placing our health in open market economy is that out of ten cardiac drug eluting stents if done for Coronary Artery intervention, eight stents in the private/corporate healthcare institutions of the city are performed without proper indications or any minimum scientific justification, and o8/10 are done with genuine indications in medical colleges. The fact is here a reality. There is danger of private health care in the capital being based on the open market, which is now so common in this state. The burden of out-of-pocket system is found to be the highest 67% (due to health tourism in West Bengal) in Bangladesh, followed by India and China, but it is the lowest in Vietnam, Malaysia, Thailand, Indonesia, Costa Rica, Bolivia, and Cuba. Cuba is still the best in health services and in health indicators, but is it possible in a socialistic economy? Poverty is highest in Nepal by almost 40% than in India (35%) followed by Bangladesh (20%), Philippines, and China (15%). According to The world Bank criteria there are two international poverty lines US$ 1.08 and $ 2.15 per head per day income, of the 11 countries, the World Bank assessed that Indonesia, Bangladesh, and Nepal had the lowest poverty threshold, in 1993. The other method of calculating the poverty line is from cost of nutritional requirement and allowance of non-food basic needs like healthcare payments, being one such requirement. When the second method of poverty line calculation is considered, Nepal shows that 40% of the population individual has less than an equivalent of $ 1.08 per day. India has the next highest rate of poverty, about 30% less than $1.08 per day. Most of the population in India lies in the $ 1 to- $2 per day section. West Bengal is a state of India with a population of 9.15 cores [2011 census], having 28% urban and 72% rural population, with 28% of the population in the working group and 64% in the non-working group (62% in the rural and 66% in the urban setup); and the percentage of population below the poverty line, that is,> US$ 1.08 per day per person income, is 35% (2007) in the rural setup and 29% in the urban setup (2007).

A study with scheduled casts showed that 38% sought private health care when their children were ill, compared to 28% who sought government health facilities in India. Another study by the author and Bhattacharya P.K et al.,[yet unpublished data], which focused on urban and the Kolkata-based poor class concluded that public health facilities were mostly used for emergency and referral purposes, but there was a preference for private practitioners for other types of cases. The implication was that the PPP of the West Bengal government resulted in a higher user fee for health and education, and finally the funding from the government drastically reduced, and the net result was the effective conversion of a free State health into a completely private one. The other step for privatization of public health care was the Health Corporation Act, 2008. Pay as and when you go to the clinic, and there was no limit for it. Local people, for example, had to sell their cows, the sole source of milk for their family, or sell their lands used for cultivation, to pay the necessary fees, which led to further malnutrition. The effect was, parallel doctors were provided with incentives in private and corporate health care clinics. The effect of all these was to deprive the majority of the local poor people, access to health care. Cutting short in the health budget could affect many health measures resulting in increased risk of dengue, malaria, tuberculosis (TB), Human immunodeficiency virus (HIV), and so on. All these diseases are increasing rapidly in the competitive open-market economy in West Bengal. The author’s experiences as a pathologist were as follows. His late 84-year-old father and two graduate brothers (in the age range of 44 years to 50 years) suffered from tuberculosis. Tuberculosis is/ was a marker disease of an extreme degree of poverty and under nutrition due to the lack of capacity to purchase food by the household.

A United Nations Development Program (UNDP) report shows that 35.8% of the population in India suffers from malnutrition and another report of the Government of India shows that among children under five years of age, the children suffering rate of malnutrition in West Bengal is 40%, in Bihar 23.5%, in Madhya Pradesh 24.3%, in Orissa 20.7%, in Rajasthan 20.8%, and in Uttar Pradesh 21.9%. Even after 65 years of independence, India [India got independence in 1947] continues to be the house of preventable epidemics, as well as, a high incidence of innumerable communicable diseases. Extreme poverty is perhaps the most important factor responsible for the poor state of health of a majority of the population in India. There has been always an unequal distribution of health and wealth in the state of West Bengal, where more than 68% of the population lives in the poverty line (PL). Food shortage, low level of income, unsurpassable poverty, and human misery exist admixed with millions and millions of people through the city slums and rural West Bengal. The inequalities exist in terms of either health status or access to health care (government or private hospitals) and in the distribution of resource allocation in the health sectors. These inequalities are found in public or in government health services (inequalities in city based hospitals, suburban based hospitals, rural based hospitals in numbers, human resources, adequate infrastructure, availability in treatment, health personal resources, and in other hospital-based services), inequalities exist in the government’s spending from the health budget for the poor, in health expenditure – between rural, urban,city areas, inequalities exist between improving the health of the poor’ and rich. These inequities can be improved by improving the conditions of daily living from before birth to old age, that is, healthy places, healthy people, fair employment, decent work, social protection, and right to health, right to food, right to education and right to live on this planet. The government of India in 2012 passed laws in parliament for Right to free education Act in govt./govt. aided Schools up to class VII standard, but the minority and Christian English medium private schools of India, those affiliated under Indian School leaving certificates (ISC/ICSC) board or Central Board school Certificates (CBSC) do not yet follow govt. acts or laws or guide lines. The Govt. of India also placed a bill in 2013 in both houses of parliament for Right to Food to BPL card holders of country at low cost for rice and cereals in minimum measured quantity, defining BPL in new terms of income i.e. INR 33/- per day per person in town, cities, urban & semi urban and INR 20/- per person per day in rural areas, that raised voices critics about new definition of BPL and how to implement.

What we probably need are twelve points to address the problem of slowing the cost of health care in the state

Right to Health, Right to have free quality health care from a welfare state and welfare country, by increasing the number of tertiary care hospitals (specialty or super specialty) in the state, possibly in every district of West Bengal, and appointing human resources there, with bonds and huge penalties if they drop out of service.Reforming of health care. Creation of a National Health Policy for uninsured poor through universal cashless health insurance along with payment reforms like pay for a performance program, electronic health record access by patients or party, electronic referring system, and development of a health information system in West Bengal. Opening more numbers of specialty hospitals in urban or suburban areas by the government can reduce patient load and referral to metropolis-based tertiary care public hospitals and medical colleges. Data generation regarding diseases pattern of a district ,subdivision, local areas are also very important and lacking in West Bengal statePrivate health insurance options, if necessary, must be under strict government control for those uninsured and small business houses – employees to be includedAll children must be insured by the government and must be immunized by the government, as per the Indian Association of Pediatric Immunization schedule, free of cost*There should be education about health at large from the school level*Preventive, long-term care, and quality health care, even at the primary level, should be provided by the welfare state government. Strengthening of Primary Health Care [at the Block level Primary Health Centers (BPHC) and Rural hospital level] with all life-saving medicines and instrumental gazettes, facilities, with proper trained technicians, instead of unnecessary patronizing for Public Private Partnership or Private and Corporate Health Care. The most efficient structure for a better health system is a strong primary care practice with the patient’s consciousness and informed consent, patients and community participation*Government subsidies for lower income group, for those in the poverty line, unemployed, and for people of the state and country below poverty lineEmployer Medicare system to provide health coverage for the employed populationIncrease the ratio of primary care physicians to specialists. Reservation of more seats in the Joint Entrance Examinations (JEE) for Post Graduate degrees /or diplomas, who will serve in the difficult zones and remote rural hospitals at least for five years after MBBS degree, or giving them extra marksIncrease the desire among physicians for practice of cost-effective and evidence-based medicine, prescribing drugs in generic name and availability of drugs and appliances through a fair-price shop, run by the Rogi Kalyan Samithi, establishing death audit [through CPC] in all types of hospitals, and fixing responsibilities for any death whatever the cause may be.Changing the outlook of physicians to write prescriptions or diagnostics or perform interventional procedures with the latest recommendation, using latest technology, as suggested by drug companies or published in low or very low impact factor indexed journals, or taking any personal gifts in cash or kind,or accepting sponsorship by the companies for traveling with or without families. Let these technologies remain in the research and theoretical fields for discussion among academics and in examinations – unless a meta analysis report with Random Control Trial results are obtained.Increase Palliative care, Decrease the life support care in ITU or ICU in private and corporate institutes* so that 70% of the healthcare costs are not being consumed by 10% of the patients of higher economic strata. It is waste-box economics. Improve long-term care for the poor and patients with diseases like Diabetes Mellitus, Coronary artery diseases, with changing lifestyles

 Acknowledgment

I am highly gratful to, Prof. Pradip Kumar Dutta MD (Calcutta Univ.), Dr. Sahidul Islam DM (Cardiology), Dr. H.R. Das DTM&H; MD (Tropical Medicine), Prof. R.K. Pandey; DM (Nephrology), Dr. Durjoy Chaudhury MBBS (Cal. Univ), DCP, MBA, Dr. Dipankar Mukherjee DM (Cal.Univ) (Cardiology), Dr. Sukumar Ghosh DM (Cardiology), Dr. Rejaul Karim MD(Radio dignosis), Prof, D.Pal MD(Chest Medicine)Dr. Tridibesh Mandal MD (Biochemistry), Dr. Sujit Sarkar MD (Biochemistry), Prof. D.N Sarkar MS, DNB FRCS, Dr. Shyamal Haldar MS (Calcutta Univ.), Dr. Pijush Kanti Roy MS (cal.Univ), Dr. Anindya Chakraborty MBBS(cal.Univ), and to many of my IPGME and R, kol-20 friends, whose names are not mentioned here, and especially to Mr. Ritwik Bhattacharya B.Com (cal), *Mr. Rupak Bhattacharya, BSc (cal) MSc (JU), Mrs Dalia Mukherjee, Mr Debasis Mukherjee of 7/51 Purbapalli, Po- Sodepur, 24 Parganas (north), and to my only daughter Miss Upasana Bhattacharya.