3 Ruinous health care

The Horse and the Groom: There was a groom who took pains to clip and comb the horse under his charge. Daily he stole a portion of the oats meant for the horse and sold it for his own profit. Despite all the grooming, the horse looked thin and unhealthy. At last the horse cried to the groom, "If you want me to be agile and healthy, comb me less and feed me more."

A farmer was detected to have diabetes mellitus. The treating doctor did frequent tests to control his sugar levels and prescribed many expensive medicines. This ruined the farmer financially and he worsened despite the "good care." At last the farmer cried to the doctor, "If you really want me to feel well again, you must care less about my diabetes and think more about the basic needs of my family."

Comments

It is estimated that about two-thirds of rural families are in debt because of health care expenditure (Phadke A, 1995). What is not realised is that this is largely avoidable. Tata group hospitals at Munnar have shown in 1993 that it is possible to treat all the illnesses in their community of about 100,000 people with medicines costing just Rs 30/- per head per year. The total health care expenditure for that year worked out to about Rs 120/- per head. These rates are even lower than the insurance premiums for health care. It is, therefore, possible to deliver appropriate health care to a community at a reasonable cost, even in the 90's. It is a shame that the Munnar model has not been more widely

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discussed and adopted by other health care providers and planners.

While considering various health care options, an ethical health care provider should be sensitive to the cost factor, and take the patient's opinion on "three A's" - acceptability, affordability and appropriateness - and two trade-offs -cost versus benefit and risk versus benefit (see Chapter 33). One must also recognise 'futzing' and avoid it. Futzing refers to activities that are mere rituals in health care which do not really help in managing a case or in improving the outcome (see Chapter8).

Referring to the inexorable downhill worsening of advanced diabetic kidney disease, despite dialysis, Prof SGP Moses of Chennai used to quip, "There are three stages in the terminal phase of diabetic kidney disease: lots of money - no urine; a little money - a little urine; and no money - no urine!” I find no better way to express the plight of low and middle income group needing expensive treatment that merely provides temporary solution to irreversible or progressive disease. By the time the Truth dawns on them, it is too late. They are in penury or worse still, in deep debt.

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As an enlightened health care seeker, you should discuss with your care provider (your doctor), the available treatment options and the relative cost-risk-benefit of these Munnar model discussed in the next chapter is a credible alternative.

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