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Income group-wise cost of medical treatment of the households: The cost omedical treatment by income group in the sampied households in the districts alsshows variation. The poor of Birbhum district (incomes below Rs. 16,000 annualhspent much more on medicai treatment than their Dumka counterparts.

The lowest income group households in Birbhum incurred an annuaT xpenditure of Rs.2,052 on medical treatment alone,which constituted 17.9percent of thei^vet^ge annual income. The same figure was Rs. 1,356 in Dumka, which constitutec12.4 percent of the ^verage annual income of these households. While the averagexpenditure on medical treatment was higher for the upper income groups (R.s. ,56in the caseof Birbhum and Rs. 3,786 for Dumka), the percentageof such expenditure to total annual expenditure was found to be sharply different.

While the cost of medical treatmeflt for the lowest income group in Birbhurrformed alarge share of thefu total annual income (17.9 percent), the figure was muclower - only 6.3 percent, for the uppermost income group. In the caseof Dumka,the averagecost of medical treatment for the uppermost income group v/as neadypercent of annual income, which was much lower than the figure for the lowesincome group (12.4percenr). t can be seen rom the graph that the lowest incomgroups - the poorest of all - suffer the most from health ailments, being more susceptibie to various diseases.The cost of treatment coflsumes a large share of theimeagre nnual ncome.cost of hospitalisation: of the 447 persons in the sampled households inBirbhum and 468 persons in Dumka (who suffered from any ailment in the year pre-ceding the canvassing of questionnaires) 88 percent in Bitbhum and 92 percent inDumka were found to have undergone medical treatment. only a small number o1hospitalisatioriswere repoted. Again, we found some variation amongst the two districts concerning hospitalisation of patients. While 3.8 percent (17 in number) of al

Chart 7 3 Annual health expenditure: by caste

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Chatt 7 4 Annual health expenditure: by income group

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f< Rs 16|{ l i - 25001- 35001- 45001- >6Ci0(x,16000 2-5000 35000 4500{-} {10000' :r ' - Eirbhum -* - Dumka


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::rients in Birbhum were reportedly hospitalised, the figure for Dumka was only 1.5:ercent (seven n number). In some of the cases, espondents mentioned that despite:ceding hospitalisation many could not avajl,of the same because of the anticipatedr'rsts involved, and the difficulties in accessinghospitals.

The averagecost per hospitalisation in Birbhum district was Rs. 9,171, while itras Rs. 2,258 in Dumka. The cost of hospitalisation included rent for beds, travel-\penses, medicines, charges for diagnostic tests and other medical expenses.

Of the totaI1.7 hospitalisation cases n Birbhum, only one was admitted to a pri-";etenursing home, the cost of which was similar to that obtaining in the public hos-ritals. However, the patient was suffering from Hepatitis and needed only three days'iospitalisation. Of the 16 patients admitted to the public hospitals only two received:ree bed and medicines.The o thers had to pay for these.

Of the total sevencasesof hospitalisation in Dumka five were reportedly admit-ied to a public hospital and the rest resorted to private treatment. !flhile the aver^gecost of hospitalisation n the pubJic hospitals was Rs. 2,302 - ranging berween Rs.600 and Rs. 5,500, he averagccost in private hospitalswas Rs. 2,150 - in the rangeRs. 2,000 - Rs. 2,300. As reported, none of the patients admitted ro the public hos-pitals was given free beds or 'medicines. (SeeAppendix tablesD | 0 and D 10.a.fordetails.)Service-wise cost of treatment: QLralified private doctors were found to be themost expensivesource of medical treatment in both the districts. Obvioush; the socio-economic differences between the two districts have influenced the expenditure pat-tern on medical treatment. \\&ile the ^veruge cost of medical treatment by privatequalifieddoctors per patient n Birbhum was Rs. 3,155, t was Rs. 1.,490n Dumka.

Public health facilities came as the second most expensive source of medicaltreatment itr both districts. The averagecost of treatment per patient (at public healthfacilities) in Birbhum was Rs 959, rvhile the figure for Durnka u'as higher (R.s. ,115).The high cost of public health care n both the districts ndicates he gradual ebbing

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Barik Shcikh, 70, is a arge farmer o{- a Birbhum village. He cultivatesmore than ten acresoi double-cropped land,having assuredirrig:rtion to*.Y., submersible:l*rl"lr He ,,s-esn:-. ": , only ro irngatehisown andbur also or h.iring ut and his assrucs

ua)'s - ph)sical lvand f inaric ia[ ] - he nou Lives poor man's i fe ar his in- laws'rcsidcnce. ,'

him a strhstantial ncome, and reladr,ely arge savings.Tlre finance accumulatedcame ro his assistancewhen he suffetocl .a'heart. ;attack. Hc spent Rs. 71,000 on treatment, ve t he ciid not have to borrow or seek assistance rom oihers. His lan4 submersiblc.t"-T:i;5ffi ;"#,il..t til:':",n.uliag.s nlrlmltncar:a*.to the fove. esa26 ear-ordonsrrucuonork-e-1 nd is,thc onl1,earning member of his fanuly.One of his legswas badly inlured following an accident Aiijul went to the subr and rs thc onJv carrung member ot Lus amtly. ()ne of hi5 legswas badly injured following an accident. Aiijul wbnt to rhe subdivisional hospital at Sian, Bolpur, and despitespendrnga substantialarnount of time and monel' at the governmeni facriiry' oundno improvpment in his conditjon. He was subsequenth'admitted to a pri'natenursing home v'here iris cg was amputarcd. He hadto spund about Rs. 90,000on his treamrent.Since he had no savingsor other assetshe haci ro sell his housc. f-landicappcd n"borh ,


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of a ftee public health delivery system. Of course there is much greater differenceberween the two districts in the degree of utilisation of public health services andtheir cost. The difference in cost between the pubJic sourcesof ffeatment in the twodistricts, perhaps 'justifies'the high degree of reliance on private services n Dumk4as the costs of the public health sources was found to be much higher in DumkaConversely, the relatively large gap between public and private (qualified) sources oftreatrneflt ensured that public sourceswere the first choice for a rclaavely higher num-bers of patients (29 percent) in Birbhum than in Dumka (12 percent).

In the caseof unqualified medical practitioners (tJMPs or quacks), there was amuch larger difference between the two districts. While tn Birbhum the averagecostof medical treatment taken from an UMP was Rs. 480 per case, n Dumka it was Rs.858. Perhaps the re'latively better accessibility of the public health services inBirbhum was responsible for a lower percentage of patients visiting quacks Q9 percent) than in Dumka (62 percent). Despite the high cost of medical treatment b\UMPs, people continued to seek their services, as the poor condition of publichealth facilities and the poor socio-economic condition of the households combineto create dependence on the services of quacks. The poor service delivery of thepublic health centres made the UMPs a better choice than expensive private doctors.The modes of operation of theSequacks (such as giving treatment on credit, readvavai-labrJitynd willingness to render service) were reportedly what attracted villagersin Dumka district to them.

While we found about seven percent of the patients visiting homoeopaths inBirbhum, in Dumka there was no case at all of patients visiting homeopaths fortreatment. The avetage cost per case for homoeopathic treatmeflt was Rs. 383.

As for the other sources of treaulent - mainly herbal medical ptactitioners(kabirEs or uaids)and witch doctors (Ehas,deysiq angarus)the average cost involvementper case n Birbhum and Dumka was Rs. 709 and Rs. 199 respectively.F{owever, veryfew people in Birbhum were observed seeing such practitioners. On the other hand, in

Dumka such practitioners were reJiedupon by 14percent of the patients, which uzs higher than thenumbet visiting public services. As we have dis-cussed n section 5, such dependencewas rrot areflection of "superstitious bel-ief", or !'abhor-rence towards moderfl medicine", but the com-pelling factor of inaccessibility and consequentinability of people to avail of modern health care.

Cost involvement, as the responses indicate,is a major factor in choosing particular health ser-vices - although not the only one. Many of rherespondents in Birbhum attributed their choiceof going to UMPs to their experience of theUMPs being iess expensive than the PHCs orhospitals. Such experierrceswere much more

Chart 7.5 Cost of treatment: by service35003000

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common in Dumka. Howeveg the cheaper-of mofe readily available private soulceswefe not cofisidefed sufficient for all the different ailments suffered by people whohad to choose expenslve sources for critical cases. n the following section we shalldiscuss the cost involvement of different ailrnents in a disaggregated form'

Ailment-wise cost of tfeatment: As mentionedin the previous section, the pattern

of ailments in the two distticts was different, yet there wefe some common diseasesthat people from the sainpled households of both districts suffeted' These werelarge\ ,io-u.h ailments, diarrhoea, the cold-cough-fever syndrome, bone relateddiseases,gynaecological problems, skin diseases,TB, etc'

While for some of the.ailments the averagecost of medical tfeatment in boththe districts v/as found to be similar, in other cases he degree of difference v/as quitenotable. For example, in the caseof cold-cough-feveq the ^vef^ge cost of tfeatmentper patient in Birbhum and Dumka was Rs. 208 and Rs. 177 respectively, but thei"rp..ti-r. costs fof the treatment of diarrhoea wefe Rs. 614 and Rs. 981' The mainfeasofrs for such similarities and differences afe complex and sociologically embed-ded - the delivery of public health sefvices, pefceptions of people about differentailments and soufces of treatments, the accessibility to vadous sefvices, the socio-economic status of the households, etc'

Let us take the case of the averagecost of tfeatment for cold-cough-fever' Inboth the districts, people considered the ailment to be of a non-setious natufe andtook the help of locally avasTableuMPs. nterestingly, in caseof this parricular ailmentthe difference in the pattern of medical treatrnent between various sources (i.e. gov-efnmeflt public health cefrtfe, qualified private doctors and UMPs) was less signifi-cant. A similar use of medicines was found on examination of the prescriptions (andmedicine foils and caftons used) by all three service providers. Perhaps, the commondegreeof effectivenessof all the t}ree major sourcesof medical attention made peo-ple depend mofe ofl the relatively cheaper and mofe easily availablesource of med-ical treatment - the UMPs. Use of UMP services for this particular ailment was fuf-ther justified by the saving of time that would accfue through pattonage of the UMPsas against visits to public and private soufces. Hence, the cost of medical tfeatmentin real terms made quacks mofe ecoftomically acceptable for this particular ailment'

In the case of tuberculosis the averagecost for medical treatrnent in Birbhumwas much lower (Rs. i,2701th^nin Dumka (Rs,2,003). The main reason behind thiswas rhat the maiority of the patients (71 percent) availed of the public health ser-vices in Birbhum, while private qualified doctofs wefe the chief soufce of such ffeat-ment (52 percent) in Dumka. The relatively high success rate of the public healthdelivery system has perhaps attfacted the majority of the patlents in Birbhum' whilethe public sector in Dumka has appatendy failed to do so'

This process has a class dimension as well. A large maiority of the TB patientsin both the districts belonged to the poorer economic classes, or whom the publichealth deJivery system was a preferred source given the financial implications ofmedical tfeatment. It was the uttefly deficient and near-defunct public health system


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in Dumka that compelled the poorer patients to seek pivate health services.A rela-tively better functioning public health sysrem in Birbhum was able ro make a hugedifference in health seeking behaviour. This finding has special relevance for districthealth administation in particulat and for the health sector of the ccuntry as awhole. When a modicum of public attention can make a significant difference inhealth seeking behaviour, there no real reason why the district health a&ninistrationin Dumka cannot make the services effective and why the Birtrhum adrninistrationcannot make such services universal. An equitable public health delivery systemwould be of immense help, particulady for the poorer sections of society.It is also worth noting here that, in both districts, peoples' own perceptionsregarding the seriousnessof the diseaseskept them away from the UMps.

The cost of treatment of other diseaseswas found to be much higher inBirbhum than in Dumka, specifically heart diseases,ENT problems, epilepsy, acci-dent iniuries, etc. A high degree of difference in the perception of the seriousnessof such diseaseswas found amongst the people of the two districts. \fhile mostpatients n such cases n Dumka were rreatedby local UMps (and in some casesbykabirEs), neady all in Birbhum sought adr,-iceand treatment from qualified prtvatedoctors.

The poot delivery of public health services becomes more visible in the caseofCh.an 7,6 Cost of treatment: by ailment


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malarn. There is r,rry litde scope for making a comparison between the trvo districtswith regard to the cost of medical treatment for malaria, since Birbhum had only twopatients. In Dumka, malatia.was a menace that many a ttme ruined households dueto the high cost of medical treatmerit. The averagecost of treatment for malaia inDumka was Rs. 611 per case the lower and upper limits being Rs. 100 and Rs.4,500).The wide extent of malaria prevalence (where all members of manv householdsreportedly suffered from mafarta) exacetbates the situation by forcing the house-holds to spend a significant portion of their annual household income on malaiatfeatment.

The cliief source of treatment for malariain Dumka, as seeri n the previous sec-tion, was the UMPs. The frequencv of maladal attacks made the quacks indispens-able, for at both public health points and in the clinics of private qualified doctorspeople need hard cash for medical treatment, whjle the UMPs ffeated them on cred-it. The sarnewas the case withkala-azaL diarchoea and othet stomach ailments. Thisindispensability has given rise to rampant drug abuse and corrupt practices in per-vasive and exploitative "health bazaars".

Nfe shail briefly examine the complexities of this market in the following part ofour discussion.

M L r r t N C T H t c o s l o i t u 4 r D i { . A tf r i A T t u 1[ N T"kog ki sabajinis be, ho1 batemare, noi bhatemare!'("Illness is not an easy hing - it kills either by hand [i.e.directly] or by [depriving oneof] rice [the main staplefoodl!").As shown in table 7.1 many households suffer from an adverse pattern of lowincome and high expenditure. At the same time, poverty, hunger and ignorance havecreated an environment that results in malnutrition and various ailments.2 Theabsenceof an effective public health delivery systemhas made things worse. \7e haveeadier discussedthe abusive and corrupt practices of private doctors (quacks as wellas qualified private practitioners). The financial cost of health care, both at the pri-vate and public facilities made people, particulady those from the poorer classes,more r,'ulnerable.

Respondents recounted many different stories about their sufferings particular-ly those concerning the arrangement of money fot meeting the costs of medicaltreatment. The money reported to have been spent in the year preceding the studywas arranged, in most cases, tom man,vdifferent sources including reguiar incomesources,savings, oans (with or w-ithout interest), proceedings from selling assetsandproperties, mortgaging of assetsand propeties, etc. Assets included livestock, trees,ornaments, utensils, bicycles, wristwatches, etc. while property inciuded land andbuildings.

In severalcases, he cost of medical treatment in both the distficts was met fromthe regular income of respondents either in full or in pan. In a significant number