I stayed in Kolkata, the erstwhile colonial capital of imperial British India, for three months this year, at my wife’s home in New Alipore.
Halfway through my stay, a family crisis erupted when my sister-in-law aged 69, was taken dangerously ill. A doctor summoned to her home advised that she needed urgently to be admitted to a specialist hospital due to complications connected to severe abdominal pains. Otherwise she would likely die.
That day she was admitted to the intensive care unit (ICU) of the Charnock Hospital – a well-equipped private facility, with facilities akin to UK and American standards, located on the Eastern By-pass. It is a super-speciality hospital providing in coronary, stroke, critical care, as well as gastroenteritis services: http://www.charnockhospital.com/charnock-hospital-aboutus.html.
Fortunately she was covered by comprehensive health insurance, by dint of her husband’s former and her son’s current employment by the local Airports Authority.
The next day family members, including myself, went to the hospital in order to find out her diagnosis and prognosis. We arrived at around 11am and waited in the modern, almost sleek, waiting area to await information on her condition.
Whilst we did, occasional raised voices could be heard from the payments desk, the most active reception booth, which was shrouded by information boards setting out the price list for different types of treatments. These concerned the need for patient families to pay in advance for continuing treatment, and about the precise amount demanded. Wads of notes were paid over by family members of patients or ‘customers’ without applicable insurance cover – the majority – who were required to pay in cash up-front for treatment.
Their alternative, if they could not or were not willing pay the prescribed charges, was to take their relative to an overcrowded general public hospital, where facilities would be much more limited, much more chaotic, with much less prospect of the delivery of suitable and timely specialised care. Indeed during that same week, a number of cases were reported in the local press where seriously injured or ill patients were unable to access the care they needed from public hospitals that resulted in their death or were forced to seek private care instead. Another motorcyclist, for instance, who had suffered a head injury in rural West Bengal was unable to a obtain treatment due to a lack of neurological resources, was forced to travel first from his district hospital to the regional Medical College nearly two hundred miles away, before being referred to a specialist neurological unit at one of Kolkata main public hospitals, another three hundred miles, where he had to wait over 14 hours to receive treatment on a corridor bench, before direct representations by his relatives to the hospital superintendent secured his admission.
Back at Charnock, at around lunchtime her son and daughter–in law were summoned to the ICU, where they were advised that their mother’s most pressing problem was a ‘leaking’ gall bladder with some element of typhoid fever also apparently present. Medicine had been ministered in an attempt to resolve or manage the problems, but the medical representative advised that in the event of a full X-ray denoting that surgery was required, the urgency of the situation meant that it may be needed to be undertaken as early as tomorrow morning, and would involve an element of potential risk to the patient.
Asked to come back early next morning, they went home in order to complete a forest of forms connected to their mother’s insurance cover to be submitted as required to the hospital in lieu of up-front-payment.
They returned to Charnock next day at 5AM. It turned out to be a very long and stressful day for them. They were told that the specialist surgeon whom would have operated could not do so as he himself had to support a sick relative, and that, accordingly, they should transfer the patient to another private super-speciality hospital – the largest such one in Kolkata – nearby: the Apollo Gleneagles.
Their next tasks were fourfold; first, to arrange transport for their mother; second, to complete the forms connected to that transfer; third, to collect the MRI scan and other test results conducted on their mother; and third, to fourthly her admission at the Apollo. This was on top, of course, the continuing uncertainty and the increasing criticality concerning their mother’s treatment plan: in short, was surgery required and what risks would it entail? After all, if the gall bladder was actually leaking, surgical intervention was needed without any further delay; on the other hand, if the problem was one of infection and fever, drug therapy might be safer and less risky compared to intrusive surgery on an elderly patient with heart problems, which could lead to the infection spreading through the blood and ultimately to sepsis: https://en.wikipedia.org/wiki/Sepsis.
Meanwhile the patient’s brother, whom I was staying with in New Alipore, had a contacted his own diabetes specialist who an Apollo consultant, to expedite the emergency admission. He promised to contact a colleague who he felt was best suited to conduct any needed surgery.
The hospital transfer to the Apollo Accident and Emergency department had only just been effected when we arrived at around 5PM. I was surprised that visitors such as ourselves were allowed to mill around the beds of this busy 20-bed emergency department, while doctors and nurses scurried around in order to respond to monitor warning bleeps or to conduct examinations, without challenge. There appeared to be a rapid through-put of patents as some were transferred to wards to be replaced by new arrivals. This churn, however, was not always quick enough, with one case reported that morning of a 54 year-old man dying in an ambulance parked outside the ward due to a bed not being immediately available.
Bad news about our family member was received that the Charnock Hospital apparently had lost the MRI results of the patient or some reason could not provide it to her son and daughter-in-law, who understandably were becoming increasingly stressed. Another problem that was communicated to me by my wife was that the resident on-call staff at the Apollo conducting the initial examination appeared to resent the fact that the family contact consultant had assigned the case to a particular surgeon. They made the case-owner consultant was a diabetes, not a gastroenterology, specialist, but my wife expressed concern that the real problem was that this meant that they would not have a claim on the insurance monies linked to the case. Apparently there was competition between doctors to ‘control’ cases for that reason, sometimes to a point where it became an organised scam.
The good news was that my sister-in-law was surprisingly lucid given her condition suggesting that the medication was working, and that the assigned surgeon arrived soon afterwards to conduct his own examination, which he proceeded to do carefully and professionally.
We went outside in the corridor to receive his feedback, which he gave in a measured and respectful manner. In essence, he advised that if the cause was a diseased or leaking gall bladder, which was the most likely cause on the evidence available, its source could be missed by limited micro-surgery; accordingly, that the safest course of action was to conduct the next day a full surgical examination and to proceed to the removal of the organ as found necessary, as the gall bladder itself was not a vital organ, but such surgery would be high risk.
This seemed to make sense to us, and we went home relieved that at least a course of action had been mapped out and would be undertaken by a by a dedicated professional who looked and acted the part.
The operation, indeed, took place next day. We attended in a dedicated waiting room provided to relatives of those having surgery, where electronic screens reported on the progress of each operation: all mod-cons, like much of the activity of the hospital. After about two hours, the surgeon called us to the theatre entrance, where he showed us gall bladder he had successfully removed from my sister-in-law and in particular its diseased ‘mouth’, which was black,decayed, and horrible. He was hopeful that the cause of infection had been removed, but cautioned that post-surgical bleeding could follow and that she was not yet out of danger, and needed to be transferred to the high dependency unit.
Fortunately she did continue to recover slowly and was able to return home after a fortnight.
That was not the end of my unplanned brush with the Indian private medical sector insofar that a friend of the family was reaching a tipping point in the treatment of his son’s kidney failure. He needed a transplant but his father’s employment-related insurance cover no longer covered his son, as had attained 25 years of age. Because the cost of kidneys to be used for such purposes was extremely high – Indian culture is not supportive of deceased family members donating their organs after death, while a public donor bank suffers from public administrative and other failures related to a lack of a national health service. Organs needed to be purchased often from living donors, which could push the costs beyond the means of a retired – albeit high-ranking – policeman, such as in this case. He thereby enlisted the support of family members to draft a letter to his insurance company requesting that he donate the needed kidney to his son conditional on compatibility checks.
What lessons were drawn from these events?
First, of course, class, money, and location counts: unless you possess the benefit of employment-related, or were able to purchase private health insurance at an annual premium cost reported cost between 12,000 to 24,000 Indian rupees per annum for a family of five (roughly £150 to £300), or had enough savings to pay for treatment as needed, if you suffered a serious accident or illness you would need to rely on the grossly under-resourced public hospital sector and take your not too bright chances accordingly. In fact 86% of rural, and 82% of urban, Indians are reported not to have any such access to insurance, explaining why 63 million of them are pushed into debt by unplanned healthcare spending each year.
Whilst not seeking to minimise the current crisis of the NHS (which also suffers from rationing, distributional, and informational issues) universal and accountable provision by the State does offers clear equity and efficiency advantages, as well a value-base or footing geared to individual need, even though that value-base can be perverted for provider and political ends as well.
Second, there is no guarantee of excellent or good treatment within the private hospital sector. Treatment is still often reliant on personal contact and power and the ability to navigate an often rigged and corrupt system where corporate and personal profit, rather than patent need, can prove paramount. Patients must rely on family members to either activate insurance policies or to negotiate payment at a time of high stress and uncertainty. The hospitals secure super-profits from the charged use of drugs and sundries in treatment, sometimes as much as 1000%. Hospitalisation costs are outstripping premium incomes.
Third, the problem of asymmetric information between provider and patient and their family members comes into particular play within such a private system: you must rely on medical advice that particular treatments are appropriate and needed given the particular circumstances of the case; the suspicion is that sometimes the treatment follows the payment schedule based on inputs rather than customised to individual need and circumstances, and best outcomes.
Fourth, and related to the third, while overall the health services are massively underfunded in India, with public health expenditure accounting at less than 1.5% of GDP, adversely impacting on both preventative and curative care outcomes, private health expenditure reimbursable from insurance and user charges continues to escalate. private providers prioritise screening consultations – with pictures of young ”yuppie- families, captioned, for example, that is never too early to prevent cancer, that inevitably result in unnecessary or over-prescribed treatments that yield additional income to the associated tests and examinations involved, which themselves often represent a diversion of scarce medical resources from alternative and more effective preventative ends. See, for example, http://apollogleneagles.in