Cost of survival

Why blood banks will continue overcharging patients despite government capping the price

Maharashtra officials have hauled up a Mumbai blood bank for overcharging patients. But the problem runs deep.

Maharashtra’s Food and Drug Administration initiated action against a south Mumbai hospital for allegedly overcharging patients for blood and its components including platelets. Last week, the hospital was issued a notice by the drug authority for selling single donor blood platelets to a patient for Rs 12,000 when the price for the same is fixed at Rs 11,000 by the National Blood Transfusion Council.

To curb the menace of overcharging, the council in 2014 had issued guidelines fixing the price of blood and its components. It prescribed processing costs based on whether the processing blood bank was privately run or run by the government. More than 2,700 blood banks operate in India which includes government, charitable and private blood banks.

Despite capping the price, blood banks continue to overcharge, said officials monitoring blood banks. Take the case of Wockhardt Hospital’s blood storage unit, which FDA officials allege was charging patients for tests they never ran. “They sold five units of platelets to patients without running a test called NAT," said Madhuri Pawar of the FDA. NAT is an advanced sensitive nucleic acid test that detects the presence of recent HIV infections in the blood. "However they charged the patient for NAT testing,” Pawar added.

Despite repeated attempts, the hospital was not available to comment on the issue.

Last year the Maharashtra FDA surveyed 310 blood banks and found that 74 were overcharging patients. However, the blood banks were let off the hook after a meeting with the State Blood Transfusion Council where they agreed to not overcharge patients.

According to Dr RS Gupta, director of the national council, around 36 blood banks in the country have been penalised for overcharging patients since February 2014, which is when the notification was passed. “The rates are fixed and all blood banks should follow it,” said Gupta.

Helpless officials

Senior FDA officials said that the Drugs and Cosmetics Act does not empower them to take punitive action against blood banks for overcharging.

“There is big loophole,” said AK Malhotra who works with the Drug Licencing and Controlling Authority in Uttar Pradesh, a state with 275 operational blood banks. “The problem is even if we find a blood bank overcharging patients the law does not allow us to suspend or cancel their licence.”

The FDA in each state is the licence issuing authority for blood banks. However, they said that there is no mention anywhere of price control as a prerequisite for a licence. “Even if they overcharge, technically they are not violating the conditions on which they were issued the licence,” explained Malhotra.

The Maharashtra FDA worked around these technicalities and asked the State Blood Transfusion Council to initiate action against the erring blood banks. In fact, this council issues a no-objection certificate to a blood bank on the basis of which it applies they apply for a licence. “We have asked the local corporation as well as the Council to initiate action against the banks,” said Pawar. “If the Council revokes their no-objection certificate, we can cancel their licence.”

This, however, is easier said than done.

In the past, blood banks that were found to be overcharging patients in Maharashtra, were left scot-free after the Council issued a warning.

Malhotra feels that the number of complaints the council gets does not reflect the extent of overcharging. “We have only got two complaints regarding overcharging,” said Malhotra. He suspects that lack of awareness about the government’s notification is responsible for the small number of complaints.

Echoing the sentiment Dr Bharat Singh, director of the Delhi Blood Transfusion Council, said that it is widely known that blood banks, especially those run by corporate hospitals, overcharge patients. “The problem is that we don’t have a provision under the current Act to take action against these banks,” said Singh. “We need a legislation fixing the price for blood. The Council has already informed the ministry about the issue.”

Singh said that patients rarely complain because they are comfortable paying for the services of an expensive hospital.

Control replacement donations instead

People working with non-profits working on blood donation said that the biggest challenge for patients is not price. “The problem with blood banks is that they expect relatives of patients to arrange for blood,” said Vinay Shetty from Think Foundation, a non-profit that helps organise blood donation camps among other activities.

Shetty receives several calls from harried relatives looking for a blood donor. “The bank can always take the blood unit or component from another blood bank but they insist that the relative brings in a donor who donates blood at their facility,” said Shetty. “Sometimes the patient’s surgery is also done but the bank insists on a replacement.”

The National Blood Transfusion Council disallows replacement blood donation. Blood banks are expected to conduct regular donation drives and collect blood voluntarily. “By forcing the relative to get a replacement, the banks are indulging in some form of coercion,” said Shetty.

Experts said that the council has made blood costly for the poor by fixing its price. “The government banks are following the price set by NBTC which is out of reach for many poor patients. They should look at subsidising the cost of blood for poor,” said Shetty.

To control this menace of replacement donors, the council has allowed blood banks to have a bulk transfer of blood and its components between them. By transferring blood between banks, the relatives of patient seeking blood will be spared from running around.

Even with blood banks rampantly flouring the guidelines, blood transfusion councils are reluctan tto take very stringent action. As Gupta explained, “If we close blood banks, the community living around it gets affected, which we don’t want.”

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.