Surgery, key to improved health; access still an issue

Public debates on access to healthcare are generally restricted to availability of hospital beds, doctors, diagnostics and medicines. Surgery doesn’t receive that much attention, though they are life-saving and routinely performed even at district hospitals. Most of the surgeries are common and do not require highly specialised units that are needed for high-end heart bypass or cancer surgeries.

Surgical procedures are expected to assume an increasingly important role in public health in both developed and developing countries in the coming years. A conservative estimate suggests that 11 per cent of the global burden of diseases can be treated with surgery.  

Are Indians from poor socio-economic background getting the benefits? Is surgery still an option only for the moneyed class? According to the Lancet Global Commission on Surgery, there are gross disparities in access to safe, affordable, surgical care worldwide, and an alarming lack of focus on widespread provision of quality surgical services. Five billion people around the world – including lakhs of Indians – can’t access safe, affordable surgical and anaesthesia care when needed.

Though there is no nationwide data, there is also no denying the fact that most of the life-saving procedures continue to remain outside the reach of maximum number of people. A proxy comes from an analysis of government medical insurance data in Andhra Pradesh and Telangana between 2008 and 2012 when 6,77,332 surgeries – excluding caesarean delivery and cataract – were performed in these two states (actually only Andhra Pradesh as the bifurcation happened later), whose expenses was reimbursed by the government under Rajiv Aarogyasri Community Health Insurance Scheme (RACHIS).

“The finding highlights a huge unmet need for operative care in Indian states in which financial access in restricted,” says the analysis. “In states like Bihar or West Bengal, the gap (in accessing surgery), is probably more, but we don’t have data,” says Vivekananda Jha of the George Institute for Global Health. Jha led a team of researchers who conducted the study.

Jha and his colleagues found that RACHIS helped the poor access surgeries substantially. The most common cause of surgery is injury (27 per cent), of which al-most 20 per cent alone involved operative correction of long-bone fractures. Next were diseases of the digestive system such as appendicitis, gall-stone removal and intestinal obstructions. Third were the problems of genito-urinary system which includes kidney stone removal.

Other surgeries relate to arthritis, heart, congenital malformations and neoplasm (abnormal tissue growth). The states paid Rs 580 crore every year as medical insurance reimbursement for surgical patients. In those four years, a whopping Rs 23,210 crore was given away by the erstwhile united Andhra Pradesh as medical insurance reimbursement.

It also shows that operative costs in India are relatively low, suggesting that the government can take care of significant morbidity if it promotes state-backed schemes to finance surgeries. Another study, conducted by the Public Health Foundation of India, too demonstrated that estimated costs are roughly comparable with the rates of reimbursement provided by the Rashtriya Swasthya Bima Yojana – the government-financed health insurance scheme that covers 32.4 million poor families – though periodic revisions are required.

Common surgeries

The PFHI team sampled the rates of 12 common surgeries in five different types of hospitals – a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed district hospital, a 655-bed private teaching hospital and a 778-bed tertiary care teaching hospital.
They found that costs of conducting caesarean section ranged from Rs 2,469 to 41,087; hysterectomy Rs 4,124 to 57,622; appendectomy Rs 2,421 to 3,616; lap and open cholecystectomy (gall stone removal) Rs 27,732 and 44,142; hernia repair Rs 13,204; external fixation Rs 8,406; intestinal obstruction Rs 6,406; amputation Rs 5,158; coronary artery bypass graft Rs 1,77,141; craniotomy Rs 75,982 and functional endoscopic sinus surgery Rs 53,398. The medicine and diagnostic costs are separate. Clearly, many would welcome financial assistance, either from the government or insurance companies.

Awareness too is a key factor. Take pregnancy, for instance. In 2011, pregnancy-related complications caused an estimated 2.73 lakh maternal deaths globally, of which 99 per cent occurred in developing countries and 65 per cent in just 11 of these countries, including India. In the developing world, the most common cause of maternal death is obstructed labour and in majority cases, the risks posed by obstructed labour can be averted by a caesarean delivery. Yet, the government data shows only about 10 per cent of institutional deliveries between 2008-09 and 2010-11 were ceasarean.

Angioplasty is another common example. Data collected by the National Interventional Council under the Cardiological Society of India from 396 Cath Labs from all over the country shows that 70 per cent of them performed less than two angioplasties per day and just about two per cent of them carry out more than five procedures per day, says senior cardiologist Praveen Chandra, from Medanta Heart Institute.

The data indicates concentration of these centres in major cities, leaving large parts of India untapped. Cardiovascular diseases remains highly under-diagnosed and only 0.3 per cent are treated through angioplasty. Chandra says if treated timely with angioplasty, only a small percentage of patients would require heart surgery at a later date. “We need to expand the scope of schemes like RACHIS because every person who needs surgery, is still not getting it,” sums up Jha.