The front page of the Mumbai edition of a leading national newspaper recently carried an advertisement of the BJP for the municipal elections due on February 21. A beaming Narendra Modi and Devendra Fadnavis were shown counterposed against a photo of a worried child with the caption “Cant afford the expenses of angioplasty… will my father ever recover?”
“Of course !” the Ad says “expensive angioplasty stent now cheaper by 85%; decision of a sensible government”.
Even if there is every reason to be suspicious of such grandstanding by a party, which has cut health budgets after coming to power, it may a good sign if electoral politics in India sees purchase in affordable healthcare. The decision by the government to cap the prices of cardiac coronary stents will undoubtedly benefit a large number of patients suffering from coronary artery disease. Therefore we must celebrate this rather unusual intervention by the state to control the cost of a life saving medical product.
At the same time, we must also acknowledge the role played by civil society organisations including the All India Drug Action Network and the newly formed Alliance of Doctors for Ethical Healthcare who kept up sustained pressure on this issue. Whilst doing so we could do well to examine whether such a step will be a one off or is the beginning of an effort to make health care more affordable to the thousands of Indians who die from the lack of affordability. This may help understand why in the first place we have to fight such dubious battles in areas which long ago should have seen definitive action. Also we must isolate the role of some of the players, as this battle is far from over & in fact efforts at obfuscation by the health care industry are already underway.
In 2014 I was appointed to a committee constituted by the government of Maharashtra to promulgate a modified version of the central Clinical Establishments Act for the state. Amongst the committee’s terms of references was a clause which explicitly stated that it had ‘suggest measures to control the escalating costs of health care’. In the first few meetings when some of us found that there was no discussion whatsoever on this part of the agenda, we raised the issue. The immediate response of a large majority of the members was that this was a ‘ difficult’ area to formulate rules on and therefore best avoided.
After much confrontation, when we persisted that this was a critical area and that we should not miss the opportunity to bring in some rationality in fees and charges we were told to come up with a ‘workable’ and ‘simple’ solution quickly. After doing some homework, largely from affordable health care models in the state, we presented a plan to the committee to lay down price ranges for charges procedures and hospitalisations based on the facility and location . This was shot down by a majority vote. The government representatives on the committee were neutral or at best vaguely supportive. The staunchest opposition came from the representatives of medical associations on the committee. We were called ‘idealists’ ‘impractical’ and even ‘anti-doctor’. One association took a legal opinion and declared that what we were proposing was ‘anti-constitutional’ and that it would move court if such a move was implemented. We were finally forced to submit a dissenting note along with the final draft of the act. Soon after we submitted the draft the state saw a regime change from the Congress to the BJP. The act has still not seen the light of day. Perhaps chief minister Fadnavis who now seems sensitive to healthcare costs could make some time to see the draft.
While it is possible that the act may come up in the future, the lesson of what I have related is that the medical profession or at least their major bodies often obstruct efforts to make health care affordable. They may be happy to pontificate about increased access but they oppose moves to rationalise charges. But what may be even more surprising at first glance is that a section may also oppose cost control on medical products and even drugs. They certainly do not promote or campaign for reduced prices. Notice the reaction of a few ‘top’ cardiologists who rubbished the current move on stent prices.
One would intuitively think that an average medical professional would be interested in providing care to his or her patient at a lower cost but that is not necessarily true. As in the case of high-cost cardiac stents, the charges often include payoffs to doctors. As for hospitals, a significant part of their income comes from the margins they make on medical products and drugs that are sold through them. The medical equipment and pharma industry offer their products at much lower costs than the stated MRP’s to hospitals who in turn ensure that only certain products are available to patients.
This is also the reason healthcare providers do not prescribe cheaper generic drugs or products even when they are available. Thus, as I wrote in a piece for the Economic & Political Weekly in 2013, the choice of brand that a doctor chooses is based on perceived quality, familiarity, marketing, availability, incentive, and maybe, affordability. And there is a disingenuous propaganda by the industry that multinational – and therefore costlier – products have a better ‘quality’ than indigenous generic versions. This entanglement and conflict of interest actually makes the industry and healthcare providers partners in selling drugs and products at higher prices.
The profit margins for pharma especially in areas like coronary stents are humungous. For example one of the leading multinationals in this market, Abbott supplies the stent to its distributor and to even public hospitals at Rs 27,000. This of course also incorporates a profit. The same stent is billed to the patient in the private sector for anywhere between Rs 70,000 and Rs 1.2 lakhs. Besides the huge profits of the company, along the way a chain of players like the distributor, the hospital and often even the cardiologist share their part of the pie. To be fair this model is not peculiar only to coronary stents but this area has come under scrutiny because of its life saving potential.
Given the current overwhelming dominance of the private sector in Indian healthcare, we seem to have arrived at a perilous situation where the interests of the healthcare industry to maximise profit and the interest of the patient to access care at affordable costs clash with each other. Stent pricing and other such matters are just tracers of this larger conflict. But the other takeaway that becomes clear is that medical professionals, their associations and the healthcare industry are unlikely to be allies in the battle for accessible care.
But then what about that critical player called the state, which historically across the world has intervened to correct the imbalance in this social need? In countries where health care is socialised through universal free coverage, such issues are non-starters. That list now includes not only Europe and Canada but also Thailand , Sri Lanka and many Latin American countries. Obamacare, which now Trump seeks to dismantle, was also essentially an effort to improve access to free care to increasing number of American citizens by controlling healthcare charges. Cuba, besides providing universal free coverage went one step further by developing several low cost indigenous products including drugs, vaccines and equipment to reduce depending on international big pharma.
In the post independence era, the Indian state too had started several initiatives towards this. Pharmaceutical companies like Indian Drug and Pharmaceuticals Limited and Hindustan Antibiotics Ltd. were launched with the aim of producing low cost drugs. Several research organisations including the DRDO were encouraged to produce low cost medical products. In fact the late President Abdul Kalam, when he was at the helm in the DRDO, collaborated in producing a low cost prototypes cardiac stent called the Kalam-Raju stent. Around the same time Dr Valiathan at the Sri Chitra institute at Thiruvananathpuram developed a cheap artificial cardiac valve of good quality. Why was this activity not expanded and these products not mainstreamed? Or did they get swept away under the sway of neo-liberal economics?
Even such questions whilst vital to the stent debate would become irrelevant if the state was the dominant health care provider implementing accessible and affordable health care and not ceded space to the private sector. Even if this seems now like some distant mirage, the state can still step in and regulate this sector, which has consistently been shown to fail when left to market forces. There has been some effort in the recent past in states like Andhra Pradesh and Maharashtra for the state to buy health care from the private sector through social insurance schemes. But these remain half-hearted measures in an area which requites serious intervention at the highest level.
Given a disinterested and hesitant state and a health care industry which is entangled primarily in profit generation, even such limited victories like the capping of cardiac stent prices are significant. But if we are indeed keen to move from patchwork to more sustainable solutions, it will need a lot of rethinking and political commitment. Those who make policy have often sorted out their own healthcare either through state sponsored funding or personal resources. Perversely though it’s good that that some of them periodically encounter the predatory nature of health care in personal or family health matters. That perhaps contributes to occasional interventions like the current case in point.
As we say in medicine treating the disease is more important than dealing with the symptoms. The disease here needs political treatment at the highest level, which does not pander to the agents, who have a vested interest in perpetuating the disease. As someone who grapples with people being denied life saving treatment on a daily basis because of lack of access and affordability I would certainly be delighted to see more Modis, Gandhis and Kejriwals staring out of the front pages seeking votes over affordable health care, which, really, is the heart of the matter. It may be the game changer.
Sanjay Nagral is a surgeon practising in Mumbai and the publisher of the Indian Journal of Medical Ethics