A Crisis of Plenty

Even as the past few decades have witnessed a steady deterioration of public health services in India, health activists and medical journals, apart from the World Bank, have been warning about our “medical overuse” crisis. This crisis has three main causes: increasing insurance cover, mushrooming of private hospitals and misuse of the financial provisions of government health welfare schemes. A recent media report points out that in the five years between 2009–10 and 2014–15, the number of major surgeries conducted under the National Health Mission (NHM) has shot up remarkably. This category which includes Caesarean section (C-section), hysterectomies and other emergency surgeries has increased by 979% in Maharashtra, 470% in Karnataka, 400% in Bihar, 258% in Jammu and Kashmir, 2,214% in Sikkim, 1,178% in Andaman and Nicobar Islands and 1,501% in Nagaland. What appears on the surface to be increasing “access” to health services carries with it not just the risk of the vulnerable and gullible being cheated financially but also having their health compromised. The poor and women pay the highest price.

The skewed scenario was further emphasised in 2014 when the World Bank warned that India’s “excessive healthcare” situation can harm patients whilst providing marginal benefits. The Jan Swasthya Abhiyan has pointed to the Rashtriya Swasthya Bima Yojana (RSBY) which offers below poverty line (BPL) families a cashless yearly insurance of Rs 30,000 as one of the schemes which is being misused by unscrupulous doctors. Then there is the Janani Shishu Suraksha (JSS) programme that offers pregnant women free delivery and aftercare with free medicines, diet up to three days or seven days depending on whether it is a normal delivery or a C-section along with a cash component if they agree to have an institutional delivery rather than at home. In Andhra Pradesh when health activists showed that unnecessary hysterectomies and C-sections were being done to claim money under the Arogyasri scheme, to its credit the state government in 2010 revised the rules. Similarly, Chhattisgarh’s “uterus scam” in which women as young as 20 were subjected to hysterectomies by doctors led to international media attention though the doctors involved got away with light punitive measures. The side effects of hysterectomy include osteoporosis, a higher risk of heart disease and tendency to depression. These poor women have access to hysterectomies but not to much simpler treatment for their other health issues. The World Health Organi­zation (WHO) has categorically said that the C-section should only be performed as a life-saving measure and that no region should have rates higher than 10%–15%. However, the national average for India was 20% in 2015 with states like Kerala showing 30%. Of course, it is no consolation that countries like China, the United States and Brazil show high percentages of unnecessary hysterectomies and C-sections as well. In these countries as well, health activists and doctors are concerned at the high rates of these surgeries apart from prescriptions of unnecessary medical tests and procedures.