India: The hidden costs of free care

Hence, many policymakers argue that to improve the health of the poor, the focus should be on strengthening and broadening services in the public sector. In reality, however, this is not the complete truth.

For the poor, accessing free care comes at a significant cost. To access care in the public sector, the quality of which is often inconsistent, the poor not only have to incur costs but also suffer a loss in income. The cost of waiting at a public health facility that does not have operating hours convenient to working patients is the loss of that day’s wage. In addition, a large population waiting to access free care ensures long waiting times, causing missed work days and consequent loss in income.

The alternative is to access the private sector. It is well known that the poor incur considerable costs towards outpatient care, deepening the burden in case of chronic illnesses and pushing households below the poverty line. Health-seeking behaviour skewed towards the private sector is born of necessity rather than choice, as patients need to access the most convenient point of care, which invariably is not the “free services’’ offered by the public healthcare system.

Take the case of an infectious disease like tuberculosis (TB). After a patient is diagnosed in the public sector where services are ostensibly free, the patient often needs to travel to access treatment. The need to access treatment regularly is critical, otherwise it can lead to a worsening of the disease, or worse, drug resistance and a more dangerous form of TB. For this, patients must incur transportation costs and several other expenses, such as costs to treat side effects and other ancillary tests and procedures not accessible at the level of primary care. The regimen to be followed for six months often demands rest, hence employment must wait. Patients also require appropriate nutrition. Therefore, expenses on food increase and others within the household must give up either their share of food or add to the household costs.

A recent study in Peru — “Catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru” by Tom Wingfield, et al (PLOS Medicine, July 15) — has illustrated the hidden costs of free care in the case of TB. This study has significant implications for high-burden countries like India, where the poorest bear the inordinate burden of this disease. It shows that, despite TB care being free, contracting TB was itself expensive for impoverished patients. The study shows that the poor have to spend a great deal to access free care. This includes “out of pocket” expenses, such as the cost of transportation, symptom-relieving medicines, or additional food, or indirect expenses associated with lost income.

TB principally affects the most economically productive age group and this directly impacts household income, with a debilitating impact on the poorest. Further, it also shows that patient and household income decreases post-diagnosis and may not return to pre-diagnosis levels, that is, the disease makes you poorer in both the short and long terms. At the broader level, it shows that catastrophic health costs may increase TB and MDR-TB transmission, especially in poorer households. This is an alarming fact for countries like India, where one poor TB patient’s disease can not only impoverish an entire family but also increase transmission. Thus, the result is not just catastrophic health costs but also weakened disease control.

These findings have enormous implications for India. Clearly, poverty exacerbates disease, particularly those like TB. But disease further pushes households into poverty. This can put families in financial shock, reducing consumption to below minimum needs, leading to selling of assets and often taking children out of school. This can also lead to increased stigmatisation and, of course, long-term poverty. Policymakers often do not understand that disease is not just a physiologically but also psychologically, economically and socially debilitating state.

They do not sufficiently see the link between losses in income due to disease and, consequently, long-term poverty or debt traps. What can they possibly do? They are, after all, only charged with policymaking in a single domain.

The recent action by the Union health minister to engage other ministries on tobacco control etc provides some direction and could indicate that the ministry would be adopting a multi-dimensional approach to provide solutions to critical public health issues confronting India’s poor. The health minister attended the World Lung Conference in Barcelona last week and stressed community-driven solutions for TB in his address to international health experts as part of the WHO symposium on TB. It is hoped that health and human development agendas would finally come together to ensure that those affected by disease are not just cured but also not impoverished, leaving them, their families and communities vulnerable to further disease.

There is little disagreement that poor households, especially those exposed to debilitating diseases such as TB, need social protection to avoid catastrophic costs, and hence extreme poverty and consequently further disease. However, we need to study these trends and facts carefully to design suitable and appropriate social protection programmes that will work for the poor. The use of technology, such as mobile banking, may provide some support.

This, however, is easier said than done, with limited funding for social protection programmes. This government, like any other, is faced with a difficult if not insurmountable situation in health. Yet, an engaged health ministry may be able to generate partnerships that can facilitate health policy formation and programme design that will ensure better access to services and increased social protection. Perhaps the most fundamental thing to realise is that the poor bear the inordinate burden of disease and, until we substantially address the social determinants of disease, the poor will always be vulnerable and free healthcare services will not save them from either disease or extreme poverty.

Source: The Indian Express