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Anatomy of a health disaster

By P Sainath

Janreddy's family survived crop failure. But debts of Rs 300,000 to cover health costs have nearly destroyed them. Loans taken to cover health costs have been a major contributor to the debt-suicide cycle in Andhra Pradesh

Janreddy sat wracked with pain, a picture of ill health. "Why isn't this man on his way to hospital," we asked the neighbours crowding around his bed. "Well," they said nervously, "we just brought him home from one. He was there for days. This family has already lost all its money on hospitals."

Janreddy died hours after we met him. His daughter-in-law, who became a bonded labourer to keep the family afloat, will remain one till debts of Rs 500,000 are paid off. Over Rs 300,000 of that was incurred on medical costs. His wife, who donated one kidney to her son -- both of his had collapsed -- does any work she can find. The son, Narsi Reddy, confined to the house, has to drink only the purest water in a place where there is none. His medicines cost around Rs 1,000 a month.

The huge medical bills of this family of six were incurred despite the son getting free operations at the Osmania Government Hospital in Hyderabad. They had first gone to private hospitals for check-ups, a biopsy and other tasks. As the costs mounted they sold off land and cattle to meet them. That Narsi Reddy had sunk four borewells didn't help. All of them failed. Crisis on their four-acre farm in Chelliagudam village of Nalgonda district saw Janreddy's health also cave in. "They might just have survived the crop failure," say the neighbours, "but their medical costs destroyed them."

Health spending is amongst the fastest growing components of rural family debt. More so in Andhra Pradesh. For years, the state boosted the private sector in health, promoted corporate hospitals and pioneered the 'user fees' system in government ones.

"The Chandrababu Naidu government dismantled the public health system," says M Geyanand, a leading doctor from Anantapur district. Dr Geyanand is also state president of the Jana Vignyana Vedika (JVV), a body that aims to promote popular science and the scientific temper. "Ninety per cent of patients who go to public hospitals are poor. When that system fails them, they turn to private ones at a huge price. Health costs often count for as much as 20-25% of the total expenditures of such households. And a single medical emergency can ruin them."

A common thread running through the farmers' suicides plaguing the state has been very high medical spending. Just five households affected by such deaths had health costs totalling around Rs 400,000. All of them farming families who held between half-an-acre and three acres of land (some of that mortgaged). Janreddy's family has not seen a suicide. But it fits this profile rather well.

As do countless other poor households. Even last year, we ran into a farmer who had attempted suicide in the Nallamada mandal of Anantapur district. His friends managed to get him to a hospital just in time. The rescued farmer abused his saviours. The reason: The four-day stay and treatment in hospital cost Rs 45,000. "I tried to commit suicide because I could not pay debts of Rs 150,000," he said bitterly. "Now I owe even more."

Many of those who succeeded in taking their lives in 2004 had huge medical bills. P Hanumantha Reddy's family in Nizamabad district owes Rs 200,000. The survivors of A Narasimhalu in Medak have to rustle up Rs 70,000 plus interest. The tab for K Shivarajaiah's family in the same district is Rs 50,000. All this was money borrowed at absurd rates of interest.

"There is a link between the suicides and the crisis of health in Andhra," says Dr Geyanand. "The collapse of the public health system is crucial. In any poor village, you can see people dying of diseases that should not kill them. Malaria is just one example. For years now, all their support systems have been slashed. The costs are so high, they run out of money halfway through treatment. Those who fall ill are selling land, gold, cattle and other assets to pay medical bills. They also take loans they can never repay."

In the past decade, the little access the poor had to health sharply declined. So Gunala Kumar discovered when he had to fork out Rs 40,000 in medical costs to private hospitals in Medak. That remains a big chunk in his total debt of over Rs 200,000. A debt that caused him to take his own life in Meerdoddi village this month. Like his father who committed suicide last year.

"Maybe it is better to die," says Yekalapu Husein of Shabuddlapur in Nalgonda. "How will we pay the fees they ask us to at these hospitals?" A toddy-tapper who suffered a fall from a tree while at work, Husein has run up huge bills himself. Then came his malnourished wife's illness. His 'medical debt' now stands at Rs 200,000. "Even if we get free care at Osmania Hospital," he laughs, "we do not have money for the bus fare to Hyderabad and back."

In G Edavalli village in the same district, the local rural medical practitioner sold all his land to pay his own treatment costs of Rs 400,000 at a corporate hospital in Hyderabad.

In the years these dramas unfolded, public hospitals were starved of funds, medicines and drugs. Given Rs 600 crore by the World Bank for public health, the Naidu government spent this mostly on buildings. Very few doctors or nurses were recruited. The buildings now show decay for lack of maintenance. Naidu also authored a government 'tie-up' with corporate bodies. Under this, employees of the state went to corporate, not public hospitals. The government reimbursed their costs. This meant a windfall for those hospitals. It also meant many scams in the shape of inflated reimbursement bills. Meanwhile, health institutions in the public sphere suffered.

"The introduction of 'user fees' made health even less accessible to the poor," says a senior IAS officer. The fees have since been withdrawn by the new state government. Also dumped was an idea of handing over some super-specialty departments of public hospitals to 'private management'. That is, to corporate hospitals.

The damage, though, has been done. The medical costs of those who preferred death to debt still plague the living. We pass Janreddy's wife at the bus stand, looking for any 'coolie work' she can find. There are, after all, bills to be paid.

This article originally appeared in The Hindu , July 1, 2004

(P Sainath is Rural Affairs Editor of The Hindu.  He received the A H Boerma Award, in 2001, for his contributions to the development debate in the Indian media. This article first appeared in The Hindu)

InfoChange News & Features, June 2005