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A major trend all over India, and exemplified by Chennai,
is the privatization of medical care. Chennai is a city renowned for and
specializing in cutting-edge medical care. With the advent of increased
prosperity, the private share of medical expenditure, even by the poor, has
grown substantially, while the share of the government has declined. Of the 500 hospitals in Chennai, 476 are
private. They process 900,000 patients every year, of whom 500,000 are from
out-of-state. Apollo, Malar, Agarwal, Vijaya, Devaki Hospitals,
Sankara Netralaya (eye hospital) and others are household words. It is the home
of several medical firsts in India
and/or Asia. These range from the first
nuclear medical oncology department (1956) to the first use of mmography (1965)
to the first heart and heart lung transplant (1995) and to a dozen other pioneering medical
treatments. When my father was still alive, he was admitted to Apollo Hospital
(pictured below) a couple of times and my mother has also been there. I was
impressed with the quality of care and service we got there.
 Even as private hospitals became renowned for their care and
cutting edge medicine, government share of healthcare in the city has been
steadily declining – for example, it went from 7.7% of its budget in the
mid-‘80s to 5.7% by the mid-‘90s. And a shrinking fraction of it is spent on
medical care (as opposed to general health). At the largest public hospital
(the Government General Hospital or “Generalaspitri”), the poor often complain
of long waits and harassment by the clerical staff. No wonder, for the hospital
is beleagured by 8000 outpatients a day and has 2000 in-patients, four times
its official capacity. By 1991,
government medical expenditure, which once dominated the sector, had shrunk to
Rs. 63/person/year versus private spending of Rs. 225/person/year.
Despite this dominance of private medicine, there are still 24
government hospitals in this city. Anyone can use these facilities, which treat
the poor (defined as families below an income threshold of Rs 60,000/year) for
free or for a nominal amount. Although these include specialty facilities and
have some state-of-the-art equipment, they are short of funds to maintain them.
Vijaya’s plight is a good illustration of the precarious
plight of most of Chennai’s urban poor with respect to medical care. If her
child broke a limb, if she contracted one of many bacterial infection
(ubiquitous in the local food and water), or anything more serious, it would be
a severe blow. The medical costs, even though they are a fraction of what one
would pay in the industrialized world, and the lost time combined would be
sufficient to draw down any meager savings. Vijaya once told me many years ago
that she had to spend over Rs. 1000 when one of her kids fell sick, and she was
absent from work for several days, losing income at the same time and risking
losing her job at these places.
My cousin, Dr.
Kalaivani, who is an obstetrician and gynecologist in Pondicherry, a city a short distance from
Chennai, has treated thousands of indigent patients for over four decades.
Access to modern medical facilities and medicines would have been difficult for
many of these patients to obtain even a few years ago. It is telling, however,
that medical insurance in India
is almost non-existent. The observations above suggest that as the country
prospers and graduates into the middle income range, replacing government run
facilities with a combination of private and
government-subsidized health
insurance schemes (such as Medicare and Medicaid) would bring big improvements. As an example,
the Voluntary Health Services was started in the 1970s to reach medical care to
the poor living in the peripheral areas of Chennai by means of an insurance
scheme with affordable premia.
The Children’s Hospital in Egmore is one of the 24 government
hospitals in Chennai and just a couple of hundred yards from our house on Egmore High Road.
When I was growing up, I was witness to the long lines of poor women with their
sick infants or children waiting in line for hours to get care for their child.
Today the same mother probably has a few more options because of somewhat
higher living standards and the availability of thousands of reasonably priced
private clinics, one of which I saw at the other end of Egmore High road during
my visit there. For Rs. 200/- ($5) a child could be treated for an injury or an
infection. Waiting lines are short and paperwork is minimal compared to
government hospitals. Medicines may be bought from the pharmacy next door.
Cheap low-tech privatized retail medical care clearly represents the stop-gap medical
solution for the city’s poor, and it seemed to be working quite well.
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