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Imagine a world where critical health decisions are influenced by the stark contrast between dire necessity and blatant overuse. In India, this scenario is not just a figment of imagination but a reality that impacts millions of families every year. The healthcare landscape in our country is marked by two extremes – a pressing need for more surgical procedures on one end and the prevalence of unnecessary surgeries on the other. Understanding these extremes is crucial to making informed health choices that safeguard both your well-being and your financial stability.
You would be surprised to know that in India, as many as 15-16% of households experience catastrophic health expenditure, meaning health expenses that have the potential to bankrupt a family. This might seem like an issue affecting poorer sections of society, but you would be wrong. Surprisingly, catastrophic health expenditure is higher in the middle-class segment. Out of 100 households suffering from this expenditure, around 57 households belong to the high to higher middle class. So, the middle class seems to be suffering more than the poorer sections.
The cost of this catastrophic health expenditure is nearly twice as much for surgical conditions compared to non-surgical care. 70% of healthcare spending comes from in-patient care, and 70% of this inpatient care cost is led by surgeries alone.
15-16% of Indian households face catastrophic health expenditure. 57% of households who face this high expenditure belong to middle class
So understanding surgeries is very important so that you can make better decisions on them and are well informed about your choices.
Let us dive into each of these 2 extremes in India.
Extreme 1: Unnecessary surgeries in India
First, let us understand what exactly is an unnecessary surgery. An unnecessary surgery is one that is not needed for the patient or is not aligned with the patient’s best interests. This definition is not easy to implement and varies depending on the context and the surgery itself. So, there is no law to prevent this; it is governed by ethics – the ethics of the doctor and the institution or hospital.
In the US, the most common unnecessary procedures are
- C-sections,
- hysterectomies,
- back surgeries,
- angioplasty or stent placement in the heart,
- gallbladder removal,
- tonsillectomy
- knee and hip replacements.
Although this list is from the US, the situation in India feels similar when looking around our family and friends circle.
Seriousness of unnecessary surgeries
The situation of unnecessary surgery in India is so serious that in a 2017 British Medical Journal article, a panel of Indian surgeons specifically called to end unnecessary operations in India.
One of the surgeries where actual coordinated action had to be taken at a national level was in hysterectomy – removal of the uterus. In a white paper in November 2023 released by FOGSI (Federation of Obstetric & Gynecological Societies of India), a renowned not-for-profit association of doctors, it was stated that nearly 67% of hysterectomies are carried out in private hospitals. However, more interesting is that 95% of these surgeries are unnecessary.
67% of hysterectomies are carried out in private hospitals. 95% of these surgeries are unnecessary.
Role of declining patient trust and traditional Medicine
Reports and news like these can hurt honest surgery advice and public perceptions. They can lead to real surgical advice not being followed by patients. Most importantly, such reports can seriously injure the faith and trust in the doctor-patient relationship.
This situation is further challenged by the wide cultural acceptance of traditional medicine. We want to emphasize that we are not against traditional medicine. In fact, numerous publications support the complementary or supportive role of traditional medicine. However, when patients refuse standard and proven medical treatments in favor of traditional medicine, it can seriously harm their health. For example, a 2018 research from JAMA Oncology reported that cancer patients who use alternative treatments or traditional medicine alone died sooner than those who opted for standard treatment. 7% of patients who opted for traditional medicine refused surgery altogether.
Patients who use alternative treatments can refuse important and standardized medical treatment
It is this wider context that can multiply the harm caused by unnecessary surgeries, undermining patient trust and pushing them to unproven treatments. The biggest cost of this trust breakdown is paid by the patient and their family. To avoid this humongous cost, it is important that the decisions for surgery are taken on more practical grounds and not on emotional grounds.
Extreme 2: Need for more surgeries in India
India needs more surgeries per 1,000,000 people. It is estimated that 30 million surgeries happen each year, but India needs 50 million surgeries annually, leading to a deficit of 20 million surgeries. The Lancet Commission for Global Surgery set a target of 5,000 surgeries per 1,000,000 population, but India currently performs only 1,385 surgeries per one lakh people – just 30% of the target. Even with a lower target of 3,646 surgeries per one lakh population described in another study, only 40% of the surgical need is met in India.
India falls short of the Global Target of 5000 surgeries per one lakh population. The average current rate of surgeries in India is 1385 surgeries per 1 lakh population
India falls short in surgeries as compared to other developed nations and also its neighbor China:
Source: World Bank
There is also significant difference between the states when it comes to the number of surgeries. Only eight states have managed to meet the requirement of 3,646 surgeries per one lakh population. The disparity in the top five largest total GDP states, such as Maharashtra, Gujarat, Karnataka, and Uttar Pradesh, have lower than 2,000 surgeries per one lakh population. Large states like Gujarat and Uttar Pradesh have a double whammy of having lower than two beds per 1,000 population (i.e., 200 beds per one lakh population).
Source: Population-level surgical rates and unmet need in India, GDP of Indian States, State-wise estimates of current hospital beds
Maharashtra, Gujarat, Karnataka, and Uttar Pradesh, have lower than 2,000 surgeries per one lakh population. Gujarat and Uttar Pradesh have a double whammy of having lower than two beds per 1,000 population
Steady growth of surgeries in India
From the perspective of growth in the number of surgeries, there seems to be a growing trend, which is good news (see image below). However, if you see the major surgeries, which is the blue line, it has remained constant. This indicates that the minor surgeries segment has been the growing segment and not major surgeries. Minor surgeries are those procedures that do not require hospital admission or complex anesthesia. E.g. Cataract surgery used to be very complex in the olden days, but today with lasers it is done in a few minutes. Today lasers are also used in minor procedures like mole removal, skin tag removal, genital warts removal, scar treatment etc. which has significantly improved the cosmetic outcomes as well.
This positive trend also indicates the adoption of more advanced technologies, such as laser technologies, which have significantly reduced surgery time, converting many complex surgeries that needed hospital stay into simpler procedures.
Minor surgeries are driving the growth trend in India, and technology has a major role in driving this growth
What can you do to avoid these 2 extremes?
We have now seen the two facets of surgeries in India, so the question is how can you save yourself from either extreme? How do you know which surgery is unnecessary and which one is necessary? The only way to protect yourself and properly understand your surgical care plan is by asking questions and understanding every aspect of surgery before you make the decision to go ahead or not.
Practical Tips for Making Informed Decisions
So what can you do to avoid unnecessary surgeries and get the necessary ones? Here are some practical and level-headed tips to help you make more informed decisions:
- How necessary is the surgery?
- Timeline for surgery
- The cost of surgery, even if you have health insurance
Questions to Ask Your Doctor Before Surgery
To help you further, here are questions you must ask your doctor prior to surgery:
- Why do you recommend this surgery? What will be the consequence if I do not do the surgery?
- Can the surgery be postponed for how many days?
- What will be the estimated cost of the surgery?
- What are the risks associated with the surgery and how common are they?
- What is going to be the recovery time and what benefit can I expect in the long run?
Seek a Second Opinion
If you are not convinced by your doctor’s explanations, get a second opinion. You can also use online consultation platforms which are more convenient and fast.
Clarify with Your Insurance Provider
After getting clarity on these questions, call up your insurance provider to get clarity on the level of co-pay and room rent ceiling. This will help you calculate how much money you have to pay from your pocket and decide what room package to book for your surgery. It is always better to inform your insurance provider about your upcoming surgery to avoid hassles with claim settlements.
We appreciate your time and hope this information was helpful. Make wise health choices and always stay informed. See you in our next article.
