Is Seeking Cancer Care in Government Hospitals Really Free?

A report by the World Health Organization estimated that 55 million (5.5 crore) Indians fall below the poverty line every year due to health expenditure. It is safe to assume that the private healthcare provision plays a significant role in this. But will providing entirely government-funded healthcare solve this problem? Will converting all hospitals to government hospitals make seeking healthcare free?

Over the past few days interacting with a lot of patients at a tertiary care public hospital in Delhi has made me realize how financially challenging seeking healthcare is for the majority. How often have you heard people say, “If they can not afford private care they should visit a government hospital where treatment is free. Nobody is forcing them to go to a private hospital to seek care”? Let’s keep aside the argument around the waiting times, systemic violence, and quality of care provided in government and private hospitals, and only try to answer one question - is seeking healthcare in government hospitals really free?

“I had to borrow 100 rupees from my neighbor today to come for my appointment,” said Mr Ramesh (name changed), a 45-year-old cab driver receiving radiation therapy for oral cancer. “I earn 200-300 rupees per day. Due to my cancer treatment, I haven’t been able to work regularly for the past few months. I am the sole earner of the family and I have two kids. I live 25km away and there are days when I do not have money to even buy the bus ticket,” Ramesh said, as he broke down into tears. 

This is known as out-of-pocket expenditure (OOPE) - that is, the money people spend from their pocket to seek health care. When spent directly on seeking healthcare it is known as direct OOPE. Direct OOPE can be either due to medical expenses like doctor’s consultation fees, and the cost of drugs and medical procedures or non-medical expenses like the cost of travel, accommodation, and food for people relocating to larger cities for treatment.  When the source of income or productive hours are lost due to absence from work for treatment, it is known as indirect OOPE. As healthcare providers, we often think of expenditure on health as the money spent on direct medical care. Since this is free in government hospitals, it is easy to assume that seeking healthcare is free in these hospitals.

However, direct non-medical expenses - money spent on travel, accommodation, and food - and indirect expenses - loss of day’s wages or productive hours due to leave from work - contribute significantly to the financial burden, which is often neglected. Therefore, the farther the hospital is from the person’s house, the more the out-of-pocket expenditure to seek healthcare, even if the drugs and consultation fees are free. As treatment for cancer is mostly localized to major cities in India, cancer patients have to spend large amounts to seek care, even in government hospitals.

Even though tertiary care government hospitals are often equipped with state-of-the-art laboratories, patients still have to get investigations done from private laboratories. “The blood collection time is 9 am to 11 am and it takes 1 week to get the report. We therefore advise (cancer) patients to get tests done outside to avoid delays in treatment,” told a healthcare worker from a leading tertiary public health center in north India. This, however, is not feasible for a majority of the patients seeking treatment in government facilities. 

Mr Mohan (name changed), a 60-year-old who traveled nearly 400 km to seek care, said, “I manage to earn only Rs 1500 per month. I am living in a temple here. I can not afford to get these tests done outside.” He looked distressed as he was worried that his cancer would progress if he delayed the tests. However, he was helpless. According to a healthcare worker in the same facility, the tests cost “only 300 rupees” in a private laboratory outside. However, the fact that the supposedly small amount was equal to one-fifth of Mohan’s monthly earnings was unknown to the healthcare providers looking after him.

A week’s waiting time to receive reports for blood investigations was reported to be “usual” by few people at the center. However, this waiting period was often more than 3 months for CT scans and MRI scans. Nine out of ten patients I spoke with had had these scans done in private centers, which cost them around five to ten thousand rupees. “I was worried my cancer would grow further and so I borrowed money to get the tests done quickly,” told Mr Shyam (name changed), a 45-year-old farmer from Uttar Pradesh who was suffering from cancer of the tongue.

Even though medicines are dispensed free of cost in government hospitals, under-stocked pharmacies force people to spend from their pocket to purchase drugs from private pharmacies. “His pain is unbearable. There are times when he begs me to kill him to relieve him of the pain,” said Mr Raman (name changed), the son of a 55-year-old man who was diagnosed with late-stage oral cancer. “We were prescribed medications for pain but those medicines were not available in the hospital pharmacy. They are too expensive to be purchased from outside,” Raman said as he tried to comfort his father who was crying in pain. 

“I had 500 rupees to come here. I spent 200 rupees to travel to the hospital. I was asked to buy a medicine that was not available in the pharmacy here, so I had to spend 200 more to purchase it from the shop outside the hospital. Now I have only 100 rupees left. How will I go back home now?,” asked Ms Afreen (name changed) who was traveling from a village nearly 50 kilometres away with her sister for her treatment.

Not just patients with cancer but their caretakers also lose their jobs when seeking care in a different city. This is nearly always the case for 70% of our population that resides in rural India, where cancer care is close to non-existent.  “I used to work as a mechanic in my village. I have been in Delhi for the past 2 years for my wife’s treatment. Some days I earn some money by doing menial jobs. Most days I have to struggle to even feed my family. I have a 3-year-old daughter I also need to look after,” said Asif (name changed) as he tried to not break down in front of his wife. Loss of livelihood leads to poor compliance with treatment, as families have to return to their native places to arrange for some money in order to return to treatment. 

Is providing good quality, accessible, and affordable care that does not push people into poverty an unrealistic dream? Dr Ravi Kannan from Cachar Cancer Hospital and Research Center in Assam has proved that providing such care is possible. His center provides not only free treatment to patients but also provides free lodging and food to people traveling long distances for treatment. To further reduce the financial toxicity of cancer treatment, the center also provides ad hoc employment to caregivers of patients. For the patients who can not travel to the center, Dr. Kannan’s center provides home-based care. 

During my undergraduate training I was told, “To treat Ramu, you should know Ramu.” But do we really know the patients we are treating? Do we know their struggles? Is the treatment that we are providing in government hospitals really free? Are we trying our best to make healthcare as accessible and affordable for our people as possible? Are we treating just the disease or the person with the disease? Can the model of care provided by Cachar Cancer Hospital be replicated in other parts of the country? As we move closer to 2030 with the aim of achieving universal health coverage, it is vital we try to answer these questions.