Dr Suchi Pande's Web diary

November 20th 2005 - effects of medical tourism on Indian healthcare

A recent editorial in the BMJ by Dr Samiran Nundy gives a good overview of the problems of the indian health system.

Essentially, the editorial makes these observations:

  1. Indian government health services are mostly of a relatively low standard
    1. because of limited funds, and
    2. the huge number of patients that they have to handle.
  2. On the other hand, private health services are
    1. for the wealthy, and
    2. even then, paying more does not necessarily get you better health care (due to profit coming before health care in the priorities of many private services).

I agree completely with the above. However, the editorial also says the following:

  1. "The private health sector in India has made some impressive strides but has done so at the cost of the public sector" and
  2. that the government needs "to pay more attention to improving the health of Indians rather than to enticing foreigners from affluent countries"

These last two statements are wrong, because they rely on an implicit illogical premise. The premise being that the sum of (health care given + the health care left) is the same at all times. The conclusion that follows from this mistaken premise is that improved health care for wealthier patients means worse health care for poorer patients.

This is a well-known logical fallacy known as the zero-sum fallacy - the fallacy here being that health care is a zero-sum situation that cannot grow with demand. However, it turns out that the health care system in India is actually in a non-zero-sum situation, because health care can grow with demand. This is largely because the private sector means that health care given and health care left can both grow if the current health care given is not enough to meet the demand. The situation is more complicated than just that, of course, but that is the essential description of the mistaken premise that has led to the fallacy

If we put to one side the zero-sum premise that underpins the two statements, and look at those statements afresh, we can see that the writers are really concerned about the disparity in health care for the rich and poor in India. Furthermore, the government seems to be encouraging a growth in this gap by promoting medical tourism. This concern by the writers is a valid concern. Disparity between rich and poor is a cause of societal tension that leads to law and order problems (such as corruption and riots) if unresolved.

So it raises the question: is the private sector really necessary? Can't good government planning grow health care?

One way of answering that question is to ask what would happen if there were no private sector.

The history of the time after Independence shows that, without a significant private sector, the choices for a potential health care worker would be that they either

  1. work in the public sector
  2. not bother training to be in health care in the first place, or
  3. leave to work outside the country
This means that, in the long run, the public sector would have a stunted growth due to the lack of opportunities for its staff, and perhaps the NHS in the UK would reap the benefit of a brain drain from India of Indian doctors. This is what the record shows happened in the past.

On the other hand, the existence of the private health care sector means that, not only do the rich use it, but health care workers in India have more job opportunities, and the care system grows larger, more capable, and more competitive. This is now what is happening in India, although misplaced sops and subsidies by the government for large institutions have helped create an environment for distortions, profiteering and unethical rackets in which care for the poor has been utterly neglected.

It is in this sort of background situation that the rich (foreigners and Indians) are using India's private health care. So it is therefore actually not at the expense of the public sector over the long term. It only seems like it when viewed over a short time scale. On the contrary, as a result of the growth of the private sector, more medical talent is available and retained within the country, so that there are more health care jobs and skills available in the country, and the public health care sector faces an element of benchmarking itself against the private health care sector. The fact that the public health care sector has been left behind in the meantime is a result of bad governance, neglect and bad funding, but in a democracy, that sector will continually be prodded into improving. So by all means, rich people should be encouraged to use Indian private health care. Over time the poor will benefit more over time due to that than if the rich were not able to use Indian private health care.

Both private and public systems have a place. If there is an imbalance between the two sectors, then government is obliged to enforce more fairness. For example by taxing the private hospitals, or enforcing free treatment for a percentage of the poor. There already this kind of provision in Indian law, but it is currently badly enforced. Enforcement of such things will improve as literacy improves.

These are growing pains in a democratic country that is developing quickly. The editorial will no doubt help raise awareness of this problem, and Indians will eventually help move things towards a more equitable balance.