Money determines many things in places where insurance is not in place like India. Whether a patient is going to undergo thrombolysis or just heparin for myocardial infarction, thrombolysis for an acute stroke or just aspirin or for that matter any treatment becomes dictated by how much he/she can spend. Let us say a patient comes with chest pain and you need an electrocardiogram (Costs $2.5), a few of them are not able to afford. But if a Trop-T is suggested, most of them cannot afford. Then the dependence of diagnosis goes to enzyme levels and serial electrocardiograms which is going to delay the treatment. So it is not the question of availability but the question of affordability. Many people cannot afford thrombolysis (Drug alone cost about $50, which is a month’s salary for many people. We should remember, with thrombolysis other cost like stay in ICU, investigations are going to add up to a big packet). Of course the government is doing a great job of stocking Streptokinase for thrombolysis in all major government hospitals for free use. But then it has to be rationed. If say 5 doses are available for a month, you will tend to reserve it for an young patient than a older patient with infarction, though it will save more of the later. So how much a patient can afford, will determine the standard of care the patient is going to get. I will put in my next post another day to day problem of treating fever, where money determines ideal vs less than ideal care.
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