New Delhi: Chandni B lives in Bengaluru but her elderly aunt and uncle live by themselves in Mumbai. When Chandni’s 76-year-old uncle needed dialysis and also started showing COVID-19 symptoms, they found themselves in a tough situation.

The elderly couple does not have any family members in Mumbai and so Chandni had to arrange an ambulance and hospital for her uncle remotely from Bengaluru. She also had to find a new dialysis centre as their regular dialysis centre had stopped taking patients due to the pandemic.

Before the pandemic, the family used to pay Rs 2,500 per dialysis session at their regular centre. But in May 2020, when the family had to find a new centre for dialysis, they were charged about Rs 10,000 for the ambulance and Rs 39,000 for a single session of dialysis. The sudden jump in the cost of dialysis caught the family by surprise.

A few days later, Chandni’s 66-year-old aunt also tested positive for COVID-19 and both of them have moved to another hospital, where the hospital insists on doing the dialysis in the intensive care unit (ICU) and billing for the ICU as well as dialysis.

Prices (un)capped

The high cost of private healthcare in India is common knowledge but the COVID-19 pandemic has further distorted the prices, both for COVID-19 and non-COVID-19 care.

The central government and courts have stepped in to regulate some prices but not others. For example, the Supreme Court set a cap of Rs 4,500 on RT-PCR testing, the Delhi High Court mandated that antibody kits be sold to the Indian Council for Medical Research at Rs 400 and the government capped the prices of hand sanitisers and surgical masks.

But several vital items were left out of price regulation; this includes N95 masks, personal protective equipment (PPE), face shields, goggles, the charges for being admitted into intensive care and the overall treatment charges.

Expensive COVID-19 tests

Private hospitals have been insisting on COVID-19 tests even for patients who may not fit the government’s criteria for testing, said Inayat Singh Kakar, a health activist at Jan Swasthya Abhiyan, a network of public health groups.

“In some instances, hospitals are insisting that non-COVID patients and their family members get tested every time they need to go to the hospital or even visit the patient. These charges add to the overall cost of treatment making it very difficult for people with chronic illness who need regular treatment like dialysis,” added Kakar.

With both central and state governments not stepping in to regulate the cost of COVID-19 tests, a chaotic and expensive situation around COVID-19 testing is unfolding in India.

The diagnostics lab chain Thyrocare had briefly rolled out diagnostic packages which included COVID-19 tests. In line with what Kakar observed, Thyrocare offered these packages in response to many private hospitals making COVID-19 testing mandatory for all patients, said Arokiaswamy Velumani, chairman of Thyrocare. “Many private hospitals were insisting on COVID tests for all patients in order to carry out even non-COVID treatment,” said Velumani.

Thyrocare charges hospitals much less than Rs 4,500 for the tests, but hospitals bill the patients more, after adding their service charges such as for bio-safety measures or collecting samples, he added.

Velumani says the prices of RT-PCR testing can come down. “The cost of the test depends on the volume of tests done and the capacity to do this testing. If the government increases its volume of testing and labs increase their capacity for testing, rates can go down. We think the prices for RT-PCR tests can come down 10% for every doubling in volume,” he said.

Masked profiteering

While patients are stuck with hefty bills, hospitals are finding it difficult to procure quality equipment at affordable prices. One such item is the N95 mask.

“Working in [a] hospital during this pandemic is like Russian roulette,” said Aparna Hegde, honorary associate professor of urogynaecology at Cama Hospital in Mumbai. “In a COVID-19 ward, we know that every patient is positive but in a regular ward, you don't know who is infected. Hence, health workers need to be protected at all times. The N95 mask is vital.”

However, high prices and difficulty in procuring N95 masks have forced health workers to ration their use of the masks. “We have given each health worker five masks, numbered them and told them to wear it one by one. After six days wear the first mask, again,” said Hegde.

“N95 masks are, in fact, the most important thing for health workers right now,” she said. “While PPEs have got a lot of attention, it’s only those directly in contact with COVID-19 patients who need to wear these… all health workers don't need them. But N95 masks are needed by many more health workers and in most parts of a hospital.”

The N95 masks crisis has prompted a litigation by journalist Sucheta Dalal and anti-corruption activist Anjali Damania in the Bombay High Court asking the government to immediately cap the price of these masks.

Dalal and Damania have told the court in their affidavit that they had tried to buy N95 masks for health workers and were “shocked to witness rampant black marketing and profiteering in N95 masks”.

The affidavit, a copy of which is with IndiaSpend, said that one of the main manufacturers of N95 masks in India sold them the masks at Rs 40 and Rs 60 plus goods and services tax. When the petitioners wanted to buy another batch at these prices, the manufacturer backed out. After this, the petitioners got offers from other dealers, selling the same masks at Rs 210. The manufacturer had earlier sold the same mask at Rs 17.

This petition pointed out to the court that the government has not moved to cap the price of N95 masks--something that health activists find strange. In March 2020, the government issued a notification that N95 masks, two- and three-ply masks and hand sanitisers are all essential commodities. It capped the prices of all these items, but did not cap the prices of N95 masks.

Similar price rise has been observed across other healthcare and medical devices too. “We had to buy contactless thermometers to monitor workers in our factory. Thermometers which were available for around Rs 1,000 in January, have gone up to Rs 10,000 per piece in March,” said Rajiv Nath, coordinator of Association of Indian Medical Device Industry and the managing director of Hindustan Syringes and Medical Devices Limited, which makes the widely used Dispo Van syringes.

“However, cottage industries have mushroomed across the country now and they are trying to locally manufacture things like masks and sanitisers to meet the demand. The government is also keen on domestic manufacturing and this should help reduce shortages and bring down the prices,” he added.

“It is a seller’s market now. Anyone can quote any price and people will end up paying for it without being sure anymore of quality or who is making these items,” said Malini Aisola, co-convenor of the All India Drug Action Network.

Government slow to act

India has been slow to regulate prices during this pandemic, said Bhupendra Singh, former chairperson of the National Pharmaceutical Pricing Authority, India’s drug price regulator.

“A rational price regulation of a few mass consumption products like PPEs, masks, hand sanitisers and gloves should have been done at the very beginning of the crisis,” he said.

During Singh’s tenure as chairperson, prices of many drugs and devices, including cardiac stents and knee implants had been capped between 2017 and 2018. In India, the prices of some drugs and devices are regulated if they are brought under the National List of Essential Medicines. A government report in 2018 which Singh oversaw, said the private sector was making profits of up to 1,737% on some items billed to patients.

Singh is not in favour of courts fixing the prices of healthcare products because “the prices fixed by courts may or may not be rational. It may have a short-term purpose but finally this should be done by the expert bodies which are meant for this job”.

He said that for a leak-proof price regulation, both the Centre and states will need to regulate prices and that “fixing just the prices of consumables involved in treatment may not help as hospitals can inflate the overall treatment cost instead in endless ways”.

For example, Singh explains, the central government can regulate the prices of drugs and consumables like PPEs, sanitisers, gloves and masks. But the Centre does not regulate private hospitals in states. This is the responsibility of state governments themselves who should use their respective clinical establishment laws to fix the prices of diagnostics and overall treatment in hospitals.

(Bhuyan is a special correspondent at IndiaSpend.)

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Anoo Bhuyan

    Anoo Bhuyan reports on healthcare at IndiaSpend. She has also reported on issues of law and justice, technology and society and gender. Before IndiaSpend, she worked at The Wire, Outlook Magazine, BBC News and National Public Radio. In 2018, she won Bournemouth University’s ‘Journalist of Change’ award for her reporting on extra judicial killings in Manipur. She also received a scholarship for her postgraduate degree at the School of Oriental and African Studies, University of London. She can be reached on Twitter at www.twitter.com/AnooBhu.