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India's health care emergency predates COVID

No safety net and expensive medical bills sink many patients into poverty

The emergency room of a New Delhi hospital. COVID-19 has forced millions of Indians to seek care at expensive private hospitals whose bills often wipe out family nest eggs.   © Reuters

NEW DELHI -- Mukund Bhasin, a government employee, remembers searching all over Delhi to find a hospital bed for his wife who had developed acute breathing difficulties after testing positive for COVID. "I knocked on the doors of at least 10 hospitals before one took my wife in," Mukund said.

It was 40 km from their home, and it turned out to be a temporary arrangement. Four days after Asha was admitted, Mukund was informed that the hospital's COVID supplies were running low and Asha, whose oxygen levels were plummeting, would need to be moved to another facility.

Mukund was handed a $15,000 bill. Having no time to process the shock, he immediately pulled money out of a fixed deposit, paid off the bill and admitted his wife to a second hospital. "Asha was put on a ventilator," he said, "and the hospital billed us $400 daily for it."

India's second COVID wave is finally receding, after infecting over 30 million, killing 391,981 and making India the pandemic's second-worst hit nation, after the U.S. But while the devastation is tapering, the financial anxiety and destitution it has created will remain for some time as survivors struggle with medical bills running into the thousands of dollars.

The country's medical system has always been rife with problems, from poverty-inducing out-of-pocket costs to underfunded public hospitals to overstretched private hospitals perceived to overcharge and be used as piggy banks by local politicians.

Now family nest eggs once meant to go toward new homes, raising children, educating children and daughters' marriages are depleted.

It was the night of May 19 when Asha and her two sons tested positive for the dreaded virus. The children had mild symptoms, but Asha's condition deteriorated.

With those $400 a day ventilator charges piling up, Mukund's problems were only beginning.

The ventilator helped Asha survive for 10 days. Then on the 11th day, the hospital informed the Bhasins that Asha had suffered a cardiac arrest and died. She was 48. Mukund, 51, found himself paralyzed by a broken heart and a $6,000 bill.

"I couldn't afford to pay the second bill," he said, his voice choking with emotion. "My daughter paid it by handing over the money she had saved up for her marriage in July. The marriage now stands postponed as we have no money."

With government-run hospitals crumbling under excessive patient loads and scarce resources, millions of Indians are scrambling to be admitted to private hospitals, despite their prohibitive charges.

Due to government-run hospitals being undercapitalized, the private sector takes care of 74% of outpatients and 65% of hospitalizations in urban areas, surveys say. Indians are also put at a disadvantage by their country spending 1.7% of gross domestic product on health care, one of the lowest figures in the world.

India's private health care institutions were stretched even before the pandemic. The huge country's doctor to patient ratio is 1:10,000; the World Health Organization recommends a 1:100 ratio.

Complaints of hospitals overcharging are rampant despite a Supreme Court ruling that the government must regulate COVID treatment costs at private hospitals and cap treatment fees.

The Ministry of Home Affairs later issued guidelines fixing hospital charges in and around Delhi at $100 to $140 per day for an isolation bed, $180 to $200 for ICU care without a ventilator, and $200 to $250 for ICU care with a ventilator.

But activists say the guidelines are being ignored.

"Many hospitals are taking undue advantage of the devastating pandemic by exploiting helpless patients," Delhi-based lawyer Diksha Sabharwal said. "And since there is no foolproof regulatory mechanism in place, they are literally getting away with murder. I've received several cases of families ruined by exorbitant hospital bills."

In some cases, patients are not even informed about the government rates, Sabharwal said, calling the issue a breach of ethics. "There is complete lack of transparency in the availability of hospital beds exclusively meant for COVID-19 treatment under government fixed rates," she added.

Indians bear high out-of-pocket expenses for health care. According to the National Economic Survey 2020, Indian families pay 60% of their health care costs out-of-pocket. This is the highest figure in the world, and it directly contributes to poverty.

The survey also notes that an increase in government health care expenditures to 2.5% to 3% of GDP from under 2% can whittle people's out-of-pocket costs to 30% from 65%.

According to a study by the Public Health Foundation of India, about 55 million Indians were dragged into poverty last year due to patient-care costs, a lack of affordable hospitals and expensive drugs. Further research by Azim Premji University found that over 90% of Indians had borrowed a median amount of $200 during the pandemic, and that the impact is expected to persist.

Men stand next to the body of a relative who died from COVID-19 at a crematorium ground in New Delhi, India, May 4.   © Reuters

Aggravating the crisis further is the fact that most Indians don't have any health insurance. A health survey that was conducted in 2017 and 2018 by the National Statistical Office notes that over 80% of Indians lacked insurance. State programs offer little reprieve.

In 2018, Prime Minister Narendra Modi launched what he dubbed the world's largest health insurance plan. It ostensibly covers 107 million poor and vulnerable families, close to 40% of the population. Yet the initiative hasn't improved access to health care, according to an academic paper by Duke University researchers.

Driven by desperation, many Indians are turning to online fundraising websites like Ketto, which between April 20 and May 31 hosted 4,000 COVID-related campaigns. Of these, 40% were to pay for hospital and treatment bills. Requests ranged from $6,500 to $60,000, a Ketto representative said.

Another platform, Milaap, through the first week of June had run 2,000 COVID treatment campaigns, mostly to pay for ICU care and ventilators. The campaigns raised around $1 million.

Experts say investment and recognition of errant hospitals are the keys to providing good public health care. "Interventions from civil society organizations can have only limited effect," said a Delhi-based epidemiologist working for a leading private hospital. "The offenders [against government directives] need to be brought to book by the authorities to instill fear among wrongdoers."

The root of the problem, one doctor said, is that many private hospitals are owned by local politicians -- or politicians are at least stakeholders in hospitals. This ownership prevents the government from taking stern action. "Moreover," the doctor added, "top Indian politicians rush to get their treatments done at posh private hospitals, so they don't want to antagonize management.

"The whole system is ridden with corruption and needs overhauling."

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