Despite being one of the fastest growing economies in
the world, India ranks among the poorest achievers of
good health. The shortfall of India's health achievements com-
pared with those of, say, China or Thailand (in terms of expanding
longevity, reducing infant and maternal mortality, curbing child
undernourishment, eliminating health-cost-induced indigence,
and other indicators) is large and has been growing larger. Even
within South Asia, Bangladesh and Nepal have overtaken India in
health accomplishment, including in life expectancy.
If India's bad record in healthcare is not much discussed in
the Indian press, this neglect does not indicate the presence of a
tolerable level of healthcare in India, but reflects instead the narrow reach of the Indian news media, with its traditional neglect
of elementary education and healthcare. That neglect is, in fact,
a contributory factor to the continuation of India's health failure
and bad schooling for the population at large, since public discussion is one of the essential requirements for remedying policy
failures. Public discussion is particularly important for policy making in a functioning democracy, and it is remarkable that in the
public discussion preceding political elections (such as the Indian
general elections of 2014), healthcare tends to get extraordinary
In this collection of well-researched essays on the state of
healthcare in India, the editors (Samiran Nundy, Keshav Desiraju,
and Sanjay Nagral) have offered us a timely opportunity to understand how badly things have gone wrong in our beloved country.
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They have also offered illuminating analyses of the causes and
remedies of the observed failures.
What explains India's healthcare debacle? One immediate
account is readily available, but we must be careful not to see
more explanation there than a deeper scrutiny can confirm. India
spends a much lower proportion of its national income on healthcare than do many other nations with comparable achievements in
economic development. Seen on its own, this line of explanation
is certainly important. The fact that India allocates only a little
over 1 per cent of its gross domestic product on public healthcare
contrasts sharply, for example, with nearly three times as much by
China. We reap as we sow, and cannot expect to get what other
countries achieve by allocating much more resources-as a pro-
portion of their respective levels of the gross national product-to
There is clearly some truth in seeing India's healthcare failure
in this perspective, but the story is much bigger than that. The
low allocation of public resources to healthcare is merely one of
the relevant factors, and important as it is as an account of what
ails India's healthcare, the neglect of resource commitment probably hides as much as it reveals. As the studies included in this
important collection bring out, India's healthcare failure is far
more extensive than the resource story alone can capture.
The entire organization of Indian health care has become deeply
flawed in nearly every respect. The story that emerges from these
carefully researched studies is that of a comprehensive health care
crisis. The editors go further than that, and see in these failures
a picture of 'healthcare corruption', which is a more disparaging
diagnosis. Corruption is a charge that must not be made lightly.
But, alas, these studies bring out why this disheartening depiction
is basically correct. In the many-sided failures of Indian healthcare
arrangements, the cupidity and greed of the agents involved-at
different levels-playa distressingly important role.
There is, to start with, the reflection of a pervasive failure
in the widely observed fact that the poor find it difficult, if not
impossible, to make use even of those services that are actually
available, or can be easily mobilized. Private caregivers will not budge without the promise of payment, and even though some public services are offered freely, many critically important services are denied unless the patient is willing – and able – to offr the demanded sums, which can be unaffordably large for the underprivileged Indians.
There are many other failures to which these studies draw
attention. Medicine is often hard to get, and spurious drugs are
too readily churned out by manufacturers and distributers. That
story of culpability frequently extends to medical equipment and
Regulations to restrain pilferage and enforce accountability are
recognized as important (as they should be), but are often success-
fully circumvented, yielding a financial bonanza for the violators.
Laws governing clinical establishments, which exist in theory,
remain quite largely unimplemented.
Even at the very top of the operations, the MCI has had what
the editors call a 'long and blemished history'. In addition to the
duties of supervision and coordination of medical services that
the Council is meant to do, but fails to perform, it also has a bad
record in its designated role of looking after medical colleges (of
which there are nearly five hundred across India). In particular,
in the use of the power-and responsibility-to set up new private medical colleges, there seems to be clear evidence of fairly
I can go on adding to this dismal picture of health care in
India-of the extensive triumph of avarice over public duties
and professional behaviour-by drawing on the rich collection
of well-researched contributions to this volume. But the readers
themselves can get the fuller story from the investigations presented in this enlightening book, and can see how plentiful and
comprehensive the failures are that devastate healthcare in India.
I end this foreword by pointing to three general failures in
health care in India which may need particular attention. The
first is the amazing neglect of primary health care compared with
health interventions needed at later stages. There is certainly
more money to be made in later interventions compared with
simple preventive care and elementary outpatient attention. In the allocation of health resources, there is a massive neglect of primary healthcare, reflecting an inability to understand the critically important role of universal healthcare at the primary level, on which the entire healthcare system has to depend.
A nation's capacity to deliver basic healthcare is perhaps
one of the best markers of its concern and responsibility
for its citizens. However, as Kavita Narayan, one of the contributors to this volume, states in the opening sentence of her chapter:
India's healthcare system is broken. Only a few years ago we read
the heartbreaking story of a father and mother committing suicide
in the nation's capital. They had lost their young son to dengue
after being denied admission to multiple hospitals. In August 2016,
we also witnessed the sordid spectacle of a poor man in Odisha
carrying the body of his dead wife home because the hospital
refused to provide an ambulance. A year later, in August 2017,
shortage of oxygen supply resulted in the deaths of a considerable
number of infants in a hospital in Gorakhpur in Uttar Pradesh.
Newspapers as well as television carry almost daily reports of
medical negligence, overcharging, and substandard care. We read
reports of the widespread production of spurious drugs by pharmaceutical companies as well the bribery of doctors with trips to
foreign countries and other sundry pleasures. There are also drug
procurement scams, underhand commissions, and a widespread
racket in medical college admissions. Possibly as a consequence of
the increasing distrust in the system, there are many more reports
of physical violence against health care providers. And even the
dry, objective statistics of health indicators, which are some of the
worst in the world, essentially convey the same message of the
abject failure of our healthcare delivery.
To us the various episodes of denial of basic healthcare are
symptomatic of a deep-rooted crisis, and at a time when the trust
deficit between healthcare and ordinary citizens is at an all-time
low, it is crucial to go beyond the headlines and dispassionately
analyse one of the key drivers of the problem-healthcare corruption. Whilst it may be true that the infrastructure is weak,
and possibly under-funded, the additional corrosion caused by
corruption has aggravated matters. Hence this book.
Corruption has occupied centre stage in Indian politics for some
time now, even making and breaking governments. Corruption
in healthcare is also beginning to receive attention in the public
sphere. Most of the discussion, however, has been superficial and
confined to elaboration, moral outrage, and lament. There has
been the simplistic explanation that healthcare corruption is just a
reflection of the values of the rest of society. There has also been a
tendency of the various players to shift the blame to one another.
This book attempts to unpeel the multiple layers that contribute
to this phenomenon and join the dots to structural and systemic
problems. By doing so we also hope to suggest solutions beyond
the traditional paradigms.
India is committed to achieving universal healthcare. This is
not a particularly recent commitment. The globally adopted declaration of Alma Ata in 1978 recognized the fundamental importance of universal primary healthcare. Successive resolutions of
the World Health Organization have reiterated this commitment.
The current Director General of the WHO, Tedros Ghebreyesus,
in one of his first public statements, was clear in his call: 'All roads
should lead to universal health coverage.
It is a truism that universal care will not become a reality unless
a well-regulated, transparent, and functioning system is in place.
This is, of course, in addition to adequate financial resources and
well-trained health human resources at every level. Over the
70 years since Independence, India has established the systems
needed, but it is now increasingly realized that paralysing corruption has crippled many of the regulatory agencies, many of
the systems, and a substantial part of the practice of the medical
profession. This book arises from a conviction that the nature and
history of healthcare corruption needs to be well understood if
indeed any improvement or reform is to be realized and if we as a
country are likely to move towards universal healthcare.
The contributors to this volume are seasoned practitioners,
teachers, and researchers, and also include many practicing physicians and surgeons. Theirs is the voice of experience. We have
also been fortunate in securing brief accounts from persons who,
despite apathy and corruption, have been able, in their particular
spaces and disciplines, to make a difference.
There are several broad trends in the way in which corruption pervades the health regulatory systems and the practice of
the profession. Rakhal Gaitonde identifies them as being broadly
linked to inadequate resources, unequal access to technology, and
individual greed. Most prominent is the corruption and bad practice which drives the regulatory councils, the Medical Council
of India (MCI) and its sister councils, the Nursing and Dental
Councils. Sunil Pandya lays down the background, and details the
influence of the General Medical Council of the United Kingdom
in the setting up of regulatory structures in India. Amrita Patel
writes of her own experiences in negotiating with the councils
and the ways in which bad practices are institutionalized. Kavita
Narayan calls attention to the fact that issues of bad governance
and corruption are present even in the Complementary and Allied
Medicine (CAM) sector, better known in India as A YUSH.
There is corruption linked to hospital practice, whether
government or private, and these have different manifestations.
Doctors in government facilities are notoriously suspect of charging patients for private consultations, of malpractice in purchase
of drugs and equipment, and of rent-seeking behaviour in the
matter of transfers and postings. S.V. Nadkarni addresses some of
these issues and makes a case for better resourced and managed
public institutions. Rupa Chinai does a case study of the Justice
Lentin Commission of Enquiry into affairs at the government-run
JJ Hospital in Mumbai in the mid-1980s, a combination of 'lies,
deceit, intrigue, ineptitude, and corruption'.
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