Sunday December 16, 2018

Why More than 580 Million People in India Have Poor Healthcare?

The maternal mortality ratio -- deaths of mothers per 100,000 births -- in these states is 32 per cent higher (244) than the national average (167)

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Healthcare in India. Pixabay
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  • India’s average spending on health, as a proportion of GDP, is already the lowest among BRICS nations
  • It accounts for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 per cent of maternal deaths

July 07, 2017: Nine of India’s poorest states — home to 581 million or 48 percent of the population — account for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 per cent of maternal deaths, but do not spend even the money they have set aside for healthcare, according to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets.

The data also reveal:

— The maternal mortality ratio — deaths of mothers per 100,000 births — in these states is 32 percent higher (244) than the national average (167).

— 38 per cent and 40 per cent children in these states are underweight (low weight-for-age) and stunted (low height-for-age), respectively, higher than the national average of 36 per cent and 38 per cent, respectively, according to 2015-16 national health data, the latest available.

— Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan — with 372 million people, more than the combined populations of US, Australia, Sweden, and Greece –together contribute to about 58 percent of all child deaths in India.

The nine poorest large states — in official jargon called “high-focus”, a term that implies they need special attention — spent an average of 4.7 percent of their social sector expenditure on public health care and family welfare annually, marginally less than the national average of 4.8 percent. Social sector expenditure includes water supply and sanitation, housing and urban development.

India’s average spending on health, as a proportion of GDP, is already the lowest among BRICS nations.

The “high-focus” states are Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, Uttar Pradesh and Assam.

“In 2005, it was observed by (the) Government of India that some states were performing poorly in various indicators,” Avani Kapur, Senior Researcher, Accountability Initiative, an advocacy, told IndiaSpend. “So, these states were clubbed together as high-focus states and additional resources were given to improve those indicators.”

ALSO READ: “Dual-Disease Burden”? India’s Great Healthcare Challenge and Opportunity 

Of the nine poorest states, Rajasthan spent the highest (5.6 percent) and Bihar the lowest (3.8 percent) proportion of aggregate expenditure on public health care and family welfare, according to the RBI data on 2014-15 actual spending, lower than the budgeted 4.1 percent for Bihar and 6.6 per cent for Rajasthan.

Seven of the nine “high-focus” states report such underspending.

“High focus states allocate large amounts to social sector to improve their indicators but in reality, they spend only a small amount, compared to what is allotted,” Kapur said. “Hence, it is necessary to consider actual accounts in order to know the proper outcomes.”

So, while some “high-focus” states spent less money than set aside by their budgets, other states outspent — by proportion as ratio to aggregate expenditure — other larger states on healthcare and family welfare, but that had no relation to their healthcare indicators.

For instance, Rajasthan (68.6 million people) reported an MMR of 244 deaths per 100,000 births in 2011-13, the second lowest in India and worse off than Bangladesh and Nepal, both poorer countries, by per capita income. In contrast, Andhra Pradesh (84.6 million people), another big state, spent 4.1 per cent of total expenditure on public healthcare and family welfare but reported an MMR of 92, according to government data.

Since 2008, Rajasthan increased its spending by 0.8 per cent and its MMR decreased 23 per cent while Andhra Pradesh’s spending increased by 0.5 per cent and MMR decreased 31 per cent.

Assam, which spends 4.2 per cent of its total expenditure on health and has 31.2 million people, has an MMR of 300 deaths per 100,000 births — comparable to Rwanda and Sudan — while Kerala, which spends 5.3 per cent on 33.4 million, reported an MMR of 61, comparable to Sri Lanka and Poland.

Madhya Pradesh, which reported an infant mortality rate (IMR) — deaths per 1,000 live births — of 51 in 2015-16, spends 4.3 per cent of total expenditure on healthcare (against the budgeted 5 per cent) and is worse off than some of the world’s poorest countries, such as the Gambia and Ethiopia.

In the nine “high-focus” states, 72.6 per cent of all births were in healthcare institutions, a steady improvement but below the national average of 78.9 per cent, according to the 2015-16 National Family Health Survey (NFHS-4) data, the latest available.

Promoting community-based education on improved maternal and newborn care, and home-based treatment for newborn infections could enhance child survival in the “high- focus” states “significantly”, said a 2012 PLOS-ONE study. (IANS)

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Hospitals Worldwide Detain Patients If They Cant Pay The Bill

Earlier this month, the High Court ruled again that imprisoning patients “is not one of the acceptable avenues [for hospitals] to recover debt.

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Margaret Oliele, a former detained patient, poses for a portrait in her home in Nairobi, Kenya. VOA

Doctors at Nairobi’s Kenyatta National Hospital have told Robert Wanyonyi there’s nothing more they can do for him. Yet more than a year after he first arrived, shot and paralyzed in a robbery, the ex-shopkeeper remains trapped in the hospital.

Because Wanyonyi cannot pay his bill of nearly 4 million Kenyan shillings ($39,570), administrators are refusing to let him leave his fourth-floor bed.

At Kenyatta National Hospital and at an astonishing number of hospitals around the world, if you don’t pay up, you don’t go home.

The hospitals often illegally detain patients long after they should be medically discharged, using armed guards, locked doors and even chains to hold those who have not settled their accounts. Even death does not guarantee release: Kenyan hospitals and morgues are holding hundreds of bodies until families can pay their loved ones’ bills, government officials say.

An Associated Press investigation has found evidence of hospital imprisonments in more than 30 countries worldwide, according to hospital records, patient lists and interviews with dozens of doctors, nurses, health academics, patients and administrators. The detentions were found in countries including the Philippines, India, China, Thailand, Lithuania, Bulgaria, Bolivia and Iran. Of more than 20 hospitals visited by the AP in Congo, only one did not detain patients.

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A relative adjusts the oxygen mask of a tuberculosis patient at a TB hospital on World Tuberculosis Day in Hyderabad, India. VOA

Millions possibly affected

“What’s striking about this issue is that the more we look for this, the more we find it,” said Dr. Ashish Jha, director of the Harvard Global Health Institute. “It’s probably hundreds of thousands, if not millions of people that this affects worldwide.”

During several August visits to Kenyatta National Hospital — a major medical institution designated a Center of Excellence by the U.S. Centers for Disease Control and Prevention — the AP witnessed armed guards in military fatigues standing watch over patients. Detainees slept on bedsheets on the floor in cordoned-off rooms. Guards prevented one worried father from seeing his detained toddler.

Kenya’s ministry of health and Kenyatta canceled several scheduled interviews with the AP and declined to respond to repeated requests for comment.

Health experts decry hospital imprisonment as a human rights violation. Yet the United Nations, U.S. and international health agencies, donors and charities have all remained silent while pumping billions of dollars into these countries to support their splintered health systems or to fight outbreaks of diseases including AIDS and malaria.

“People know patients are being held prisoner, but they probably think they have bigger battles in public health to fight, so they just have to let this go,” said Sophie Harman, a global health expert at Queen Mary University of London.

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Detained patients lie on beds in the Kenyatta National Hospital in Nairobi, Kenya. VOA

Hospitals often acknowledge detaining patients isn’t profitable, but many say it can sometimes result in a partial payment and serves as a deterrent.

‘A way to conduct business’

Festus Njuguna, an oncologist at the Moi Teaching and Referral Hospital in Eldoret, about 300 kilometers northwest of Nairobi, said the institution regularly detains children with cancer who have finished their treatment, but whose parents cannot pay.

“It’s not a very good feeling for the doctors and nurses who have treated these patients, to see them kept like this,” Njuguna said.

Still, many officials openly defend the practice.

“We can’t just let people leave if they don’t pay,” said Leedy Nyembo-Mugalu, administrator of Congo’s Katuba Reference Hospital. He said holding patients wasn’t an issue of human rights, but simply a way to conduct business: “No one ever comes back to pay their bill a month or two later.”

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FILE – A Yemeni woman suspected of being infected with cholera receives treatment at a hospital in the capital Sanaa. VOA

Global health agencies and companies that operate where patients are held hostage often have very little to say about it.

The CDC provides about $1.5 million every year to Kenyatta National Hospital and Pumwani Maternity Hospital, helping to cover treatment costs for patients with HIV and tuberculosis, among other programs. The CDC declined to comment on whether it was aware that patients were regularly detained at the two hospitals or if it condones the practice.

Dr. Agnes Soucat of the World Health Organization said it does not support patient detentions, but has been unable to document where it happens. And while the WHO has issued hundreds of health recommendations on issues from AIDS to Zika virus, the agency has never published any guidance advising countries not to imprison people in their hospitals.

‘Cruel, inhuman and degrading’

Many Kenyan human rights advocates lament that hospitals continue to hold patients despite what was seen as a landmark judgment in 2015.

Back then, the High Court ruled that the detention of two women at Pumwani who couldn’t pay their delivery fees — Maimuna Omuya and Margaret Oliele — was “cruel, inhuman and degrading.” Omuya and her newborn were held for almost a month next to a flooded toilet while Oliele was handcuffed to her bed after trying to escape.

Cholera, hospitals
A doctor gestures outside a hospital in the Algerian town of Boufarik, as the country faces a cholera outbreak. VOA

Earlier this month, the High Court ruled again that imprisoning patients “is not one of the acceptable avenues [for hospitals] to recover debt.”

Omuya said she is still psychologically scarred by her detention at Pumwani, especially after another recent run-in with a Nairobi hospital.

Also Read: Kenya’s First Breast Milk Bank to Combat Newborn Mortality

Several months ago, her youngest brother was treated for a suspected poisoning. When Omuya and her family were unable to pay the bill, the situation took a familiar but unwelcome turn: he was imprisoned. Her brother was only freed after his doctor intervened.

“Detentions still go on because there are no rights here,” Omuya said. “What I suffered, I want no one else to suffer.” (VOA)