How clinics affect classrooms

BLURRY BLACKBOARDS Disadvantaged families dig deep into their pockets to get their children essential medical care. Illnesses often force them to burn through money intended for fees, tuitions and guidebooks

Nikki Sharma, 16, was prescribed glasses last December, but despite her struggle to read the blackboard in class, it took eight more months of blurry vision before she finally got a pair of specs.

“First it was demonetisation, and then it was the GST,” said her father Lavkush Sharma who earns between ₹12,000 and ₹15,000 a month as a carpenter. “It was impossible to find any work for months after she was diagnosed.”

Glasses cost only ₹500, but Nikki didn’t get a pair until her family found some for free. Her mother Rekha Sharma was running errands when she bumped into a local charity giving glasses away.

“I went home, grabbed Nikki’s prescription and ran back to the camp,” Rekha said. “I wanted to get her spectacles before the exams.” The delay was torturous: Nikki’s glasses represent to her parents not their child’s comfort so much as the whole family’s high-stakes bet on her future success.

Exam season, which starts in a few months, determines where kids go to college. College, in turn, determines careers. Nikki has her heart set on attending Lady Shri Ram College, one of the city’s best liberal arts institutions.

But none of that will be possible if she can’t read the blackboard.

It’s a story you hear again and again in Sangam Vihar — how poverty and illness reinforce each other. The aspirations of disadvantaged families are often a single sickness away from vanishing.

A VICIOUS CIRCLE

Sangam Vihar is a sprawling, unplanned settlement on the city’s southern flank, the first port of call for rural families seeking a toehold in the national capital. The intersection of poverty and health found here is a national phenomenon.

From 2004 to 2014, healthcare expenses pushed an estimated 7% of India’s population, or about 80 million individuals, below the poverty line, according to a Brookings Institute analysis of data gathered by the National Sample Survey Office. By 2014, health costs accounted for 10% of annual expenditure for one in four Indian homes, up from one in five in 2004.

According to Samik Chowdhury, an assistant professor at the Institute for Economic Growth who has written extensively on poverty and healthcare, chronic underfunding had crippled India’s public health system from primary health centres all the way to super-specialty institutes like the All India Institute of Medical Science.

Government spending accounts for only a third of healthcare expenses in India, according to the National Sample Survey Office. The rest is paid by individuals unable to access the public health system.

“Study after study shows that poor households are disproportionately affected by healthcare costs,” said Chowdhury. “High healthcare costs may act as a deterrent to treatment, meaning that poor households may delay seeking medi- cal care, which in turn may aggravate the ailment and push up medical costs.”

Illnesses force poor families to burn through money intended for private school fees, extra tuitions, and expensive guidebooks, all necessities for success in India’s fearsomely competitive exam system.

One of Nikki’s classmates, Reena Jha, 17, has had to face an extreme form of this predicament. Three years ago her father, Govardhan Jha, 52, who worked as an assistant at a printing press, collapsed unconscious at home with a brain haemorrhage.

“He fell ill on a Sunday morning, we took him to the Safdarjung government hospital, but the senior doctor wasn’t in,” said Devi, Reena’s mother. Govardhan lay unconscious on a hospital bed for a whole day without medical attention before a nurse told the family to take him to a private hospital for treatment.

“It cost two lakhs to treat him,” Lalita said. “We are still in debt to friends and family.” Govardhan didn’t start working again until this past June. Reena and Lalita say he hasn’t fully recovered and falls ill easily.

Meanwhile, even though she’s in her crucial board year, Reena has had to forego math tuitions since the summer because of the cost of treating her father’s debilitating medical problems.

At the beginning of the school year, Reena said she wanted to go to college and become a chartered accountant. This is a well-paying profession: though wages for an entry-level position range from only ₹15,000 to ₹25,000 a month, they rise

to ₹40,000 a month after just two years, accordingly to a survey by Teamlease, one of India’s largest labour contractors.

But mid-way through the year, Reena’s plans changed.

“Now I think I should just get a job and do college through correspondence,” Reena said as her eyes welled up. “I need to think of our financial condition.”

THE COST OF HEALTHCARE

According to a 2010 paper by Peter Berman, Rajeev Ahuja, Laveesh Bhandari published in the Economic and Political Weekly, 80% of families pushed below the poverty line by healthcare expenses were most severely affected by the steady dripdrip of outpatient care.

Rekha, Nikki’s mother, has been struggling with dizziness and headaches for years, which makes it difficult for her to do house work. Nikki and her younger sister Nisha often do the cooking and cleaning, which eats into time that could be spent doing homework.

Rekha receives treatment at Safdarjung Hospital. The consultation is free, but her medicines are unavailable at government hospitals, so must be purchased from private chemists. Rekha’s migraine drug, Rizact-10, costs ₹52 a tablet.

“In government hospitals the doctors are good and the consultation is free,” said Lavkush, “but we spend about a third of my salary each month on medicines.” He added that accompanying Rekha to government hospitals take a full day, forcing him to miss out on their salary.

THE ALTERNATIVES

For routine medical problems, Nikki, Reena and much of the rest of Sangam Vihar go to Dr BA Khan, one of the neighbourhood’s best-known private doctors.

Dr Khan and his five young assistants operate out of the Ekta Clinic, a set of three interlinked storefronts that serve as a waiting room, a consultation room, and an ersatz ward, with two beds where patients can be admitted for a few hours during the a day.

The clinic charges ₹40 for a consultation, often with a few pills of Crocin and some vitamins thrown in for free.

A heavyset man with a kindly manner, Dr Khan was trained as a Bachelor of Ayurvedic Medicine and Surgery, which Sumit Mathur, another assistant, cannily mistranslated as Bachelor of “Allopathic” Medicine and Surgery.

BAMS is a certified five-year degree, and its practitioners are allowed to prescribe allopathic medicine in the state of Maharashtra, much to the exasperation of the Indian Medical Council, which has contested this government decision in court. In Delhi, the policy on traditional doctors is hazy and the subject of contentious litigation with both sides claiming victory.

“He’s a good doctor, he’s inexpensive, and his clinic is open till late,” said Lavkush. “I can take the children after work. His clinic is a short walk from our home.”

There is little research on the quality of care provided by Bams-certified doctors such as Dr Khan.

But a 2016 paper by the Abdul Latif Jameel Poverty Action Lab on the quality of care provided by “informal medical providers” — essentially people like Dr Khan’s assistants, who have no degree in medicine at all — found that they correctly diagnosed illness in 52% of all cases. The figure rose to 60% after a ninemonth training programme.

By comparison, trained doctors in government-run primary health centres correctly diagnose their patients 67% of time. These findings suggest that someone like Dr Khan, who has a five year degree, a decade of experience, and largely positive patient feedback, is likely doing a reasonably good job of filling a pressing need.

“I see about a hundred patients a day,” said Dr Khan, explaining that he set up his clinic 10 years ago when he was visiting a

Study after study shows that poor households are disproportionately affected by healthcare costs. SAMIK CHOWDHURY

Assistant professor at the Institute for Economic Growth

friend. “Sangam Vihar is very populated, and very polluted too. I could see its people needed an inexpensive clinic.”

Most of the time, the Ekta Clinic serves a triage centre: routine illnesses are promptly dealt with, complicated illnesses sent on to government hospitals, and emergency cases stabilised while the patient’s family summon an ambulance. Dr Khan’s patients trust him completely.

“I’m getting treated at Batras,” said a middle-aged woman waiting her turn in Dr Khan’s waiting room. Batra Hospital is an expensive multi-specialty hospital across the road from Sangam Vihar. “I just want Dr Khan to look at my prescription to confirm its okay,” she said.

MOHALLA CLINICS

In March this year, the Delhi government opened a neighbourhood clinic in Sangam Vihar to provide free medicine and healthcare. It should save residents the trouble of having to go all the way to Safdarjung Hospital for minor coughs, colds and fevers.

The clinics have been the cause of bickering between the Delhi government, which wants to expand the project, the city’s Lieutenant Governor, who has raised objections about the rental rates for the clinic premises. As a result, construction has moved at a slow pace.

Initially, the Sangam Vihar clinic served 20 patients a day. As word spread, Dr Vinod Kumar, a young government doctor fresh out of medical school, started seeing over 100 patients every day.

“School finishes at about 12:30, so by 1 we get a lot of parents and school kids,” he said. “We’re seeing a lot of dengue, malaria, chikungunya and diarrhoea cases.”

People at the clinic are largely happy with the treatment, though the sheer numbers of patients points to the scale of Delhi’s healthcare problem. A hundred cases over a four-hour shift leaves Dr Kumar two minutes per patient. The clinic may already have hit full capacity.

On September 5 this year, the Lieutenant Governor gave his approval, paving the way for a massive expansion of the programme. If successful, the new clinics will make it easier for children like Nikki and Reena to seek timely healthcare, and cushion the financial burden of illness.

“I’m just praying that everyone in my family stays healthy till my boards,” Reena said. “Otherwise, things will get very difficult.”

LAVKUSH, carpenter