Two separate reports relating to health and healthcare in Punjab released last week have underlined that the poor, especially in rural areas, remain the most vulnerable to cancer. Their inability to pay medical expenses decreases their chances of survival, and plunges them further into poverty.
The first report, released by Tata Memorial Centre (TMC), Mumbai and Postgraduate Institute of Medical Education and Research(PGIMER), Chandigarh said more cancer patients in rural areas die than in urban parts of the state, mainly due to late diagnosis of the disease.
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The second report, released Thursday by PGIMER and Public Health foundation of India, pointed out that about 77 per cent of expenditure on health was borne by households and individuals, while the government’s contribution was around 20 per cent. Spending on health impoverishes 3.3 per cent people in the state annually, the report said.
In 2013, TMC and PGIMER set up four population-based cancer registries (PBCR) to cover a population of 4.4 million in four districts. Data was collected from Chandigarh and SAS Nagar (urban districts), and Mansa and Sangrur (rural districts) in Punjab.
According to the report, in SAS Nagar, an urban district of Punjab better known as Mohali, 767 new cases were registered in a population registery of 5.73 lakh. In Sangrur, there were 798 new cancer cases that year in a registry of 9.02 lakh people. Mansa had 403 cases in a registry of 4.19 lakh people.
About the incidence rates of cancer in male, the report said that in SAS Nagar, there were 74 cases per one lakh population, while in Sangrur and Mansa there were 43 and 45 cases respectively. About the female incidence cases, the report noted that in SAS Nagar, there were 104 cases per one lakh population, while as the cases registered in Sangrur and Mansa were 52 and 55. The registries also recorded 322 deaths in SAS Nagar; in Sangrur it was 448, and in Mansa there were 233 total number of deaths was 233.
“The survival rate of cancer in men in rural areas was 35 to 40 per cent, while in women the survival rate is 45 to 50 per cent,” Prof J S Thakur, Department of Community Medicine, PGI, the principal Investigator of the report told The Indian Express. “In urban population, the survival rate of male is 50- 60 per cent and 70 per cent in women.”
Thakur said the difference between the rural and the urban town is the lack of facilities and awareness among the people. “In 2013, there was no facility in rural areas. Even the diagnostic centres were in these areas.”
He, however, said there has been an improvement in the health infrastructure of late.
Experts attribute the lower survival rates in rural areas to less access to healthcare facilities. “Survival rate in rural areas is less because the low income group doesn’t have money for treatment,” said Dr Inderjeet Singh, Professor and Head, Economic Department, Punjabi University Patiala. “Health system is dying down [in the state] and today if one wants to save the patients then he has to be taken to a private hospital only.”
Dr A K Nanda,Professor, Center For Research In Rural And Industrial Development in Chandigarh. had the same view. “Private sector too provides facilities in rural areas, but poor people can’t opt for such facilities as they can’t afford,” Nanda told The Indian Express.
The TMC report also pointed out that in SAS Nagar, the highest number of registered cases among males was lung cancer, while it was oesophagal cancer among Mansa and Sangrur men.
Cervical cancer is the second leading cancer among women in three districts of Punjab taken together in 2013, after breast cancer. But in Mansa, a rural district, cervical cancer was the most prevalent form of the disease.
Medical experts say sexual transmitted infection causes the cervix cancers.
“Human papilloma virus (HPV) [sexually transmitted infection] is a necessary cause for cervical cancer in more than 99 percent of cases,” said Dr Vanita Suri, Professor, Department of Obstetrics and Gynaecology, PGI told The Indian Express. There is no awareness about cervical cancer in rural areas, its causes or prevention, she said.
The PGIMER-Public Health foundation report sheds light on why there is little disease awareness. Only 6 per cent of all health expenditure, private and public, is on preventive care. All preventive care is carried out at present by government entities. A high 46 per cent is spent on curative care, and 27 per cent on outpatient care.
The government’s health expenditure in 2013-14 was Rs 13,414 crore or 4.2 percent of its Gross State Domestic Product(GDSP); 86 percent of overall public health expenditure was spent on wages and salaries.
More than half of private health spending, 54 per cent, was on the consumption of medical goods and medical services, in which 32 percent was spent on diagnostics.
“The private sector [in health] over the years has grown very strong. In government sector we have less manpower and if we have doctors, they are less qualified,” said Dr. Inderjeet. “These days, patients choose private hospitals to survive, only those who don’t have any option go to government hospitals.”
Dr Rajesh Kumar, head, Department of Community Medicine, PGI says the report reflects how health expenditure is pushing people into poverty. “The government’s contribution ro healthcare should be increased three-fold,” he said, “to make public healthcare more effective.”
The state government said the focus is on rural and poor pockets of urban areas. “A lot has been done over the last few years to improve the health services, but certainly there is scope to do more and we are working on it” said Vini Mahajan, Principal Secretary Health & Family Welfare Punjab. “Evidence is that the great heathcare need is in the rural areas and in poor pockets of urban areas, so special attention is given to these areas.”
Where the government has made an effort, it has made a difference to people’s lives.
Nanda cites the state’s maternal healthcare service as a good example of what effective public healthcare could do. “Earlier patients were visiting the private sector for maternal health services, but now the trend has changed because the infrastructure for maternal health in public sector has improved across the state,” he said.
He also cites the example of Chandigarh’s government hospitals. “Public is forced to visit private hospitals because they get quick services there. If people in Chandigarh can visit government hospitals why not in Punjab. Because the Punjab hospitals lack infrastructure and facilities,” said Nanda.
Dr Ranjeet Guru, Deputy Director, Punjab Health Department said the percentage of mothers delivering babies in state’s public sector hospitals is now higher than private sector. “Under various government schemes, we are conducting deliveries free of cost across the state,” said Guru. “We provide facilities to pick the mother from her home before the delivery and then drop her once the baby is born.”
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