This post is a submission by Dr. R. Srinivasan, an ENT specialist from Coimbatore, with decades of experience in medical practice. He responds here to the two posts CRI carried recently, “Does India Need UHC?” by Jaideep Prabhu, and “How (Not) To Make Healthcare Affordable,” by Prashanth Perumal. His experience in the field certainly adds to CRI’s discussion of key issues that will affect India in the coming years.

As an editorial aside, CRI wishes to thank him for his thoughtful contribution to the debate. We welcome submissions from our readers on any issues they may have an expertise on, and see our venture as a space for free and open debate of issues across the political spectrum (yes, we even allow Leftist views to be aired for target practice!).

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Universal Health Care (UHC): The word health in this term is often misunderstood and used with a completely different context to imply medical care and that is the root of all confusion.

To explain, health is the normal natural state of an individual. All the ‘normal’ i.e ‘healthy’ person has to do is maintain his ‘normalcy’ and the body usually takes care of itself.

Maintenance of health – normalcy, depends on clean air to breath, clean water to drink, nutritious and hygienic food to eat and a clean living environment which is not conducive to the occurrence of disease. Given these ideal settings most human beings can expect to have a healthy life span till apoptosis – ‘programmed cell death’ tips the balance and the individual dies. Modern active disease prevention strategies like immunisation also help in avoidance of disease. However, all human beings will suffer from minor illnesses like coughs, colds, aches and sprains from time to time but these are usually self limiting and will be dealt with by the body itself.

Health is lost due to many reasons. Ill-health may be clearly self inflicted due to smoking or due to partly understood reasons like diabetes or may be due to completely unknown reasons like a brain tumour. Medical care in the form of doctors, paramedical staff, technologies and drugs is usually required in such circumstances to cure and restore normalcy or, if not possible, alleviate symptoms and comfort the individual.

It can thus be stated that health care and medical care are completely different. Absence of health care will certainly lead necessitate medical care but medical care cannot substitute health care. Maintenance of normalcy – health care, requires a supply of all the parameters needed to maintain health. It does not require doctors, drugs or treatments! A ‘normal’ person becomes ‘abnormal’ when the preconditions for a healthy lifestyle are not met and only then medical care is needed to make the unhealthy normal again.

Should health care be assured and universal? The intrinsic merit of universal health care is clearly explained in the Charaka Samhita:

“…dharmaarthakaaman moksaanam aarogyam moolam uttamam
rogaas tasyaapahartaarah sreyasah jivitasya ca

“…health is the ultimate root of righteousness, wealth, happiness and liberation.
Diseases carry it away as well as happiness and life.”

Without good health an individual cannot expect a meaningful life and without life the purusharthas cannot be achieved. It can therefore be said that the right to good health is as fundamental as that of life itself. In this aspect what holds good for an individual applies to the entire society and therefore UHC is a must! Provision of all parameters required for a healthy life and not doctoring is what is meant here by ‘UHC’.

Providing medical care without addressing the root causes of ill health is like treating the symptoms and ignoring the disease! Faecal contamination of food causes typhoid. Providing doctors and drugs to treat typhoid all the while ignoring poor hygiene is complete waste of resources.

Universal Medical Care (UMC): Even after full provision of facilities needed to live a healthy life and avoid disease, it is inevitable that human beings will fall sick and need treatment from the medical industry. Medical care involves treating the sick to make them healthy again. Suffering or dying due to lack of medical care is inhuman and ideally anybody who is sick should have access to medical facilities. However medical care entails costs and then questions like who bears the costs, should services be rationed and if so on what basis all arise and are debatable.

If it is conceded that the right to Life is fundamental, the ways and means to be alive can also be considered an elemental right. If it is agreed that clean air, water and food are vital ingredients for a healthy life, one also has to acknowledge that the medical treatment needed when things go wrong and shorten life is also a fundamental necessity. These cardinal rights need to be universal and assured and ought not be constrained by the paying capacity of a person. Moreover it should also be understood that diseases caused by contaminated food, water and environment not only affect single individuals but sometimes entire communities. Plague, small pox and cholera used to wipe out entire populations. Likewise a single sick person can also ruin the health of many for example, tuberculosis (TB). A person coughing TB germs can spread the disease to every one of his contacts. Such a person is a health hazard to one and all and should be made ‘safe’ no matter his ability to pay for treatment.

Such basic needs absolutely essential for all human beings should be accessible to every person and not be dependent on the person’s ability to purchase such services. Since these facilities have to be offered to all irrespective of their ability to pay they may not be conducive to traditional market oriented ‘for profit’ private enterprise. In a private set up a sick person is exposed to a triple whammy, first, he has lost health, second he incurs expense to recoup his health and third he funds the private player’s profit! Should a profit be made out of another person’s distress?

I would make bold to say that health and medical care ought to be universal but since the topic is so complicated and fraught with social, ethical and economical ambiguities, I would be the first to concede that funding, costs, rationing and access are all eminently debatable.

Out of the two, health care is mostly provision of infrastructure like clean drinking water, proper sewage, waste disposal, prevention of pollution etc. Initial costs may be high but may not require periodic huge spends. Having said that, resources are finite and have to be rationed. For example, if the daily requirement of clean water for a person is ‘x’ litres, x times three litres with some additional margin to accommodate parents (based on the family planning slogan “we two, ours one”) can be allotted to a family. Any excess requirement for the household has to be bought at extra cost. It must be emphasised that such excess requirements should be sold to individual households only after the basic requirements of the community are met. This is to stop a wealthy person filling his swimming pool just because he can afford all the extra water!

Provision of sound health care facilities will curtail the incidence of common problems like diarrhoea, dysentery, typhoid, malaria etc and vastly reduce the burden on medical facilities, especially in India.

Provision of universal medical care is the more contentious but almost everybody would agree that to allow a fellow human to suffer sickness because of inability to afford medical care would be considered unacceptable in a civilized society. Medical treatment is a costly affair and in these days of rapid technological advancement, periodic huge spends are sometimes common and necessary. Who provides the services and who foots the bill?

The medical services: Private medical concerns (including health insurance companies) work for a profit and are very good at providing services but with profit as motive. The price for medical treatment in a private concern will always be costs plus profit. Should fundamental needs like medical care be a commodity sold for profit? It should be understood that a sick person has already lost precious health, stands to lose money by funding treatment, can lose income due to absence at work and in a private set-up funds the profit of the service provider. Is it ethical to make a profit out of such distress?

It is said that private enterprise with competition reduces costs and maximizes efficiency. This would be applicable if the motive is to make a profit, ‘create wealth’ etc but the aim here is to provide medical care for all, not to merely make a profit. Increased competition can also have unintended consequences in the form of unethical behavior as highlighted by Carmen Nobel in the paper, “When Business Competition Harms Society” published in The Harvard Business School Working Knowledge Weekly Newsletter, dated June 11, 2012. Increasing competition in private medicine may initially lead to reducing cost to the patient but eventually, quality will also be lost. Faced with falling margins and the prospect of going bust, most private players will be tempted to cut corners to stay afloat. Subtle unethical practice in medicine is quite easy to do, difficult to detect and easily justifiable.

That leaves only medical care provided by ‘public sector’ hospitals. Certainly not in the present form but only after a complete radical overhaul. A paradigm shift has to occur before medical care can fully be entrusted to the public sector but to discuss those issues would entail digression from the topic on hand. More on that later.

The bill: Making medical care ‘free’ merely shifts the costs elsewhere – as there is no free lunch there is no free treatment. The unpredictable nature of health and sickness make individual health planning fraught with uncertainty. Robust health today does not guarantee a disease free tomorrow. Likewise sickness, treatment and recovery are also completely unpredictable. One cannot choose to have bypass surgery on his seventieth birthday and keep on going for another ten years! Moreover treatment costs have an unerring tendency to escalate with time and private medical care can sometimes impoverish a family.

Usually a person hedges against these eventualities with insurance. However, most insurance companies are private business and their concern is with maximising profits and keeping shareholders happy.  Settling claims reduces profits and no wonder ‘pre-existing disease’ cases are denied coverage and occasionally even genuine ones fobbed off.

The only solution to this would be if medical treatment costs are funded by the tax payer. A separate medical levy which should be a percentage of the total household income should be collected from all households with the exception of the most indigent. Any operational deficit should be topped up with tax receipts.

The easily avoidable diseases would have been prevented by sound health care and the ‘unavoidable’ illnesses (ex breast cancer) would be taken care of by this scheme. That leaves the self inflicted diseases like those caused by smoking. Should the society pay for an individual’s irresponsibility?

Human nature being what it is, expecting everybody to behave sensibly would be simply wrong. However people who chose to have habits which are proven to be risky and injurious to health must be made to pay for their follies. This should not be in the form of denial of medical care but rather by increasing the monetary cost of their habits. For example a separate ‘treatment levy’ should be collected on every pack of cigarettes, unit of alcohol, unhealthy junk food, sugary drinks etc. People are free to enjoy what they want but they pay the price for their enjoyment!

Likewise, medical care is a finite resource and has to be rationed. Brahmacharis (children) and gruhasthas (householders) should have priority over resources than vanaprasthas (retirees). This does not mean that vanaprasthas are denied treatment and left to die but members of the community with present (householders) and future (children) potential get priority over the retirees and that too only in certain peculiar circumstances, for examples, transplants, prolonged intensive care stay etc.

Health and treatment when health fails can be assured to every human being only when the services and costs are publicly provided and funded. A set of the population would always not be able to afford private medical care and suffering due to such circumstances should be unacceptable in a just and fair society. Do we not become hypocrites if we say lokaas samasthaas sukino bhavanthu and let an infant die for the lack of two hundred rupees?

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Jaideep A. Prabhu is a specialist in foreign and nuclear policy; he also pokes his nose in energy and defence related matters.

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