in india, care depends on who you know

this is the seventh piece in a series about how india keeps solving the wrong problem.

i’ve put this one off. it’s the hardest to write, because it isn’t abstract for me. in the last five years i lost two people i loved, one of them recently, and a lot of what i now understand about indian healthcare i learned in those rooms.

so i’ll keep the personal part short and plain.

i watched a private hospital get a diagnosis wrong. not once. and i watched what it takes to get things to actually move when someone you love is slipping. it takes phone calls. it takes knowing someone who knows someone. a name you can drop, a number you can ring.

we had a few of those calls to make. and even while making them, i kept thinking the same thing.

what happens to the person who has no one to call.

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the system that makes the call necessary

the calls aren’t a quirk. they’re the predictable output of how we’ve built things.

india spends about 1.9% of its gdp on public health. the government’s own target, set years ago, was 2.5% by 2025. we didn’t get there. it’s one of the lowest levels of public health spending among major economies.

so the public system, the one that’s supposed to catch everyone, is chronically starved. and the gap gets paid by you, directly, at the worst possible moment.

out-of-pocket spending, the money families hand over themselves, climbed back to around 43% of all health spending in 2022-23, after years of slow improvement. that’s among the highest in the world. roughly one in six households faces health costs large enough to be called catastrophic. an often-cited estimate puts the number pushed into poverty by medical bills in the tens of millions a year.

that’s the quiet violence of it. illness doesn’t just hurt you. it can take the house.

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so we built escapes instead of fixing it

faced with a weak public system, we didn’t fix the public system. we built ways around it.

we built private hospitals, which now deliver the majority of treatment in the country. and we built health insurance to pay for them.

both are real, and both are leaky.

insurance looks like protection until you need it. of the claim value people filed in a recent year, only around seventy percent was actually paid out, and rejections have been rising. the fine print, the waiting periods, the deductions, the “not covered,” all of it lands on you while you’re already frightened.

and the private hospital, paid per procedure, has an incentive that doesn’t always point at your health. the clearest evidence is caesarean sections, where peer-reviewed work found the odds over four times higher in private facilities than public ones, a large share of them avoidable, driven by money rather than medicine. when the payment rewards doing more, more gets done, whether you needed it or not.

this is the same move from the pollution piece in this series. the shared thing fails, so we each buy a private escape from it. and the escape sorts people by what they can afford.

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and then there’s the part you can’t buy

money gets you through the door. but the last stretch, the part where things actually move, often runs on something money can’t directly buy. connections.

the right call to the right person. the friend who’s a doctor. the relative who knows the administrator. the name that turns a queue into a priority.

and the shortage underneath is real, especially outside the big cities. however you count the national doctor-to-population numbers, rural india faces severe shortfalls, with specialist vacancies running around eighty percent at many community health centres.

so the doctor you need may genuinely not exist near you. and whether you reach one of the few who do can come down to who you know.

that’s the line that stays with me. in a fair system, the quality of your care wouldn’t depend on the quality of your phone book.

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the wrong problem, in a hospital corridor

here’s where it connects.

we decided the problem was how to pay for care. so we built insurance. we decided the problem was where to get care. so we let private hospitals fill the gap.

we never seriously decided that the problem was building public care good enough that you don’t need to escape it, or call anyone, in the first place.

so the burden slid, as it does in every piece of this series, onto the individual. pay out of pocket. fight the insurer. find the connection. and if you can’t do those things, take what’s left.

i could make those calls. that’s not a comfort. it’s the problem stated plainly. my people got a better shot because of who we happened to know, and that means someone else’s people got a worse one for the same reason.

we built everything around care, the paying, the escaping, the networking, except care that simply works for whoever walks in.

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what i carry out of it

i don’t have a fix, and i’m not going to pretend grief gave me one.

but i know what the right problem is now, and it isn’t a better insurance plan or a longer list of contacts. it’s a public system funded and staffed well enough that a stranger with no money and no connections gets the same fighting chance my family did.

until that exists, the honest thing is to at least name it. the calls we make aren’t proof the system works. they’re proof it doesn’t, for everyone without a phone full of the right names.

if you’ve sat in one of those corridors, you already know all of this in your body. i’m sorry. i’d still rather say it out loud than pretend the workaround is the system working.

next, i want to look at what happens when you turn to the one institution that’s supposed to step in when things go wrong. the police, and the strange trap of a system that won’t help you and won’t let you help yourself.