Postcode lottery - two village women

My blog entitled Behind the Beautiful Facades – brought in more comments than any other to date.
I was encouraged by this one, from the director of a grant-making body:

‘ I’ll certainly be conscious that there is more to healthcare than having our plaque on a wall when it comes to picking projects for us to support next year.’

The beautiful facades blog touched on an absurd kind of postcode lottery that is developing in rural Bihar. Absurd because it is based on the faulty premise that building bigger and bigger hospitals and running them like business corporations will mean better eye services for the poor. In reality the opposite is happening – because eye doctors want to make their own decisions about where and how they work and are less willing for their skilled surgeons’ hands to be hired ones.

But what are patients experiencing as a result of all this? (That’s what one responder wanted to know). 
So let’s step into the shoes of two village women.

Aurangabad district, south-west Bihar.

I picked out Lalsha Kuwar from the 100+ post-operative patients because she looked much younger than the rest. It turned out that she was 49, indeed young to have bilateral blinding cataract.
I examined her at the slit-lamp and reassured her that her cataract surgery had been successful. She agreed that she could see well but continued to look anxious.
Later I saw her sitting in the hospital corridor. We had a chat, woman to woman rather than doctor and patient.
She was a widow. Her husband died in a road accident. She had a job - cooking the midday meal for children at a government school. Her monthly salary was 1,600 rupees (about £16). She had noticed that her vision was deteriorating rapidly and suspected that she had motiabind  (cataract). She had heard that there were hospitals in Bihar that offered free surgery. But often middlemen took money for transport to a big hospital far away and there were hidden costs once you had reached hospital – the purchase of post-operative drops and the dark protective goggles worn after surgery. In this way, patients could end up parting with 1,500 rupees – almost her entire monthly income.  

At a village screening camp she met a young man called Ayan who worked for Drishti Eye Care Hospital. He told her that she would not have to pay anything at all, that in fact she was a priority patient because of her predicament. His was a hospital committed to helping people like her. What’s more, it was located in her own district of Aurangabad.
She was loath to believe him. But it had turned out to be true. She had been treated well by the doctors, nurses had explained how to put in her eye drops and she knew that it was important to attend her next follow-up examination. She had not been charged for anything.
Hospital staff then announced the departure of vehicles going back to the villages. As she stood up to join her fellow patients, she managed a small smile.

Saran District, north-west Bihar

70 year-old Seema Devi (not her real name) was standing outside the closed gates of the huge rural eye hospital in her small village.
Social worker Harshvardhan came across her. It was he who described what happened next.

Seema was told by a security guard that she had to phone for an appointment – he pointed at a notice with the relevant number. Only then could he allow her through the gates. H offered to help her. He used his phone to call the number.
They were given a time for her appointment – and about 20 minutes later a loudspeaker announced her name. She was then admitted into the courtyard of the hospital. At the first ‘station’ she was asked her name and age and if she had an Aadhaar card (an identity card). She was then asked to sign a non-disclosure form, releasing the hospital from any responsibility in adverse circumstances. She was asked to pay a registration fee of 300 rupees (£3).
At the next station a young ? optometrist (she did not identify herself) asked her what her problem was, tested her vision with a hand-held electronic device and told her that she would have to put in drops to dilate her pupils. When the drops had worked their effect, another member of staff examined her eyes and told her that she had cataract and would need an operation in the right eye. She was then sent to sit before another table.

Said H: ‘On the table were piles of lenses used in cataract surgery. And they told her the price of each lens, starting with small sums and rising to very large sums. But it was obvious that she could not afford them. So I asked them about free or subsidized surgery – everyone knew that the hospital offered this. They lost interest in us and said ‘then she must go to a screening camp.’ I insisted that she lived just next door to the hospital, so why should she go to a screening camp far away? They said –‘take it up with management’.

The pair then tried to find the management office. En route they came across a patient who had been identified with cataract at a village screening camp and had had surgery. He had paid 1,500 rupees for his treatment. He didn’t mind he said, because he was from the neighbouring district of Arrah and they said the money had to be taken for transport, food etc. It seems the hospital only held screening camps outside their own district of Saran.

At this stage a kerfuffle broke out. A family who claimed that they had paid 64,000 rupees (around £640) for a cataract operation were not happy; they had returned several times to the hospital to see a doctor and were told that they could not. They mouthed off about the bad treatment they had had and warned others not to bring their family members there. By this stage Seema lost her nerve and asked to leave.

Summarised H : ‘So by the time we came out, she had spent three hours at the hospital, was 300 rupees poorer, more confused than when she went in, and wondered who the hospital was for if not for people like her, who lived in the very village in which the hospital was located.’

NB

Both hospitals are charitable eye hospitals. They are operated by Indian Trusts that pledge that they are not-for-profit establishments. They receive donations to help their work.
The first is run by a small group of local people. It has a staff of around 40 including 4 doctors. It was set up to provide permanent and comprehensive eye services for the people of Aurangabad district. And that is what it does.

The second hospital advertises itself on its website as ‘the largest eye hospital in northern India’ and ‘one of India’s top 5 eye hospitals’. Its trustees and advisors include men associated with large Indian corporations like Tata Motors and Sony. It has all the media trappings of a business. But it benefits hugely from that not-for-profit status. One American NGO has pledged $1million towards a $4million project to construct a new 350 bedded hospital in Saran district. (Yes, really – you can watch the YouTube appeal made by the hospital boss, thanking the good folks of America for this ‘legacy’ for the people of Bihar).

This is what they proclaim on every conceivable social media platform:
‘… the hospital works in eradicating curable blindness by providing affordable, accessible and sustainable eye care services and empower women to achieve this.’

Lalsha in Aurangabad is back at her job cooking midday meals for schoolchildren thanks to her eye hospital experience.
Seema will have to travel out of her Saran postcode in order to feel the empowerment of accessing affordable eye care. Doesn’t seem quite right, does it?

#postcodelottery  #behindthebeautifulfacades #peoplenotprofit

Lucy Mathen