India is emerging as a favoured destination for a new kind of tourism - medical tourism. While states like Goa and Kerala are trying to woo the foreign tourist with their natural splendours, many Indian hospitals are trying to invite a foreign clientele with five star hospitality and world-class treatment facilities. The slow trickle of foreign patients’ promises to turn into a flood; this industry is reported to be growing at 15% annually. This should sound like music to our ears too. Shouldn’t we Indians all be proud that our hospitals and doctors are becoming popular not only with our cousins across the borders but also for patients all the way from the Middle-east and even the United Kingdom?

The image of a globally competitive Indian industry is being fed daily to all citizens of this country in so many different ways. We first learnt of the distinct edge that the Indian software engineers and firms had over their western counterparts before the now forgotten Y2K episode. Then it was boom time for the call-centre industry and now for a whole range of services called BPO. Some time ago we also learnt of how the Indian educational system notably the Indian Institutes of Technology and the Indian Institutes of Management could rub shoulders with the best in the business, globally. And now we learn that the Indian health sector is so good that a person in Manchester doesn’t think twice before getting her or his knee replaced by a hotshot Indian doctor in a five star Indian hospital in Mumbai.

Indeed, we have more advanced health care now than we've ever had. Our private hospitals are comparable to the best in the world, where their equipment and facilities are concerned. Our drug companies are filing for global patents and have become a force to reckon with in the international markets. Hundreds and thousands of young Indian doctors leave these shores to train abroad. Many stay back in their adopted countries but many return and start working in the world class hospitals which are now found in all large Indian cities.

What is a matter of grave shame though is that despite such ‘achievements’, an overwhelming proportion of Indians do not have any access to reliable health care services. And if there is one sector in which the schism between Bharat and India is the widest and deepest it is in the health care sector. While the Constitution claims that India is a ‘socialist republic’ it has perhaps the most privatized health care system of the world, even more than ‘capitalist’ USA. This has an almost catastrophic consequence for the poor Indian. While the number of primary health centres across the country is impressive, in most places the services are unavailable. Even ten years after coming up with plans for making emergency obstetric care available to the poor the systems are still not in place. The name of the scheme, however, has undergone two or three metamorphoses and in the meantime the maternal mortality rates continue to rise.

A World Bank study on the Indian public health system concluded a few years ago that most people who visit the government health facility can afford to pay. Moreover since over 80% of all health care expenses come out of private pockets, it was mooted that Government health care facilities should not remain free, and user’s fee was introduced. It was a misnomer to call government services ‘free’ in the first place. The poor in India also pay taxes, and as tax payers, it can be their minimum expectation to receive some basic services. Secondly the poor patients pay a hefty unofficial service charge for all the services they receive at government hospitals - from the tip to the ward boy to clean the urinal, to a ‘fee’ to the surgeon for removing an appendix. Unfortunately the large multi-state studies do not adequately explore this phenomenon.

The All India Institute of Medical Service (AIIMS) is supposed to be the acme of medical care in India and the Central Government is often promising AIIMS-like facilities in other states as well. The promise sounds good, but only till the time you realize the way poor patients are treated at AIIMS. Before private hospitals became the popular haunt for prime ministers, it was AIIMS which used to be the favourite health destination for our political masters. Even now a quick appointment, an immediate investigation or timely surgery require political connections and clout. For the poor these state-of-the-art, free facilities are available through the welfare state – but at a cost. Long delays at every counter, month-long waiting lists, frequent breakdown of equipment, etc. make it certain that other than the most persevering patient others soon make a bee-line to a private facility.

The private sector that the poor have to contend with is not the flashy Apollo Hospitals but the unregulated private practitioners found in all small towns.
Nowadays it is fashionable to say that government services are ‘weak, inefficient, and corrupt’ and hence dispensable and privatisation is the way to go. Unfortunately the private sector that the poor have to contend with is not the flashy Apollo Hospitals but the unregulated private practitioners found in all small towns and in all localities in the larger ones. Many of them hold valid medical degrees, many don’t. But other than this distinction, the quality that all of them have in common is to over-prescribe and to practice the most irrational forms of clinical medicine. There are no standards of practice, no common protocols, no norms, no regulations, and fees are charged in the most arbitrary manner. However these services are competitive and manage to cure many of their ‘clients’ and their fame grows by the day through word-of-mouth as well as not-so-subtle hoardings and banners.

In India the doctor is held in great reverence and s/he occupies a berth slightly lower than the gods in the family pantheon. And despite a large shortfall of doctors in rural areas, urban India is teeming with qualified practitioners. This should be good news for the average urban citizen who can now be certain of being in good hands when the need arises. However the facts emerging from the latest round of the census shows doctors in very poor light – as being greedy and without ethics. An ultra sound examination during pregnancy is necessary in certain conditions, but unscrupulous doctors had made it a mandatory test. Bending backwards to client needs the doctors used the ultrasound to check for the sex of the foetus. The radiologists in collusion with the gynaecologists set up large rackets all over the country for aborting the girl child. It is mind-boggling to calculate the economics of this business where even if a thousand rupees were made for each test-abortion the total amount made by doctors every year amounts to thousands of crores!

If this is also a picture of the Indian health sector, I wonder if ‘India is Shining’? And even if it is, for whom?