As I sat waiting with sweaty palms and dampened spirits among the coughing, sneezing and ailing crowd, I was informed by an impeccably dressed charming receptionist that it’s my turn to meet the doctor. Walking down the sparkling clean, pristine corridors of the hospital, I finally reached my destination. The consulting doctor welcomed me with his best smile and by the end of 10 long minutes, I was handed an infinitely lengthy list of diagnostic tests. I sat there dumbfounded and perplexed, thinking to myself, what has my body come up with that warrants a plethora of tests and X-rays? Thinking about the impending mammoth bills and the inconvenience of getting tested, I hurried down the steps to be greeted by a humungous banner in the foyer. It proudly claimed – Rated the best hospital in the city for its affordable and conservative treatment. The irony was blatantly evident.
Over the past decade, healthcare has turned out to be the most profitable and fastest growing sector in the world. The growth of “for-profit” healthcare organisations and their marketization has been exponential and unstoppable. What factors may have contributed to this widespread trend of privatizing healthcare? How has a service-oriented and patient-focused sector turned into a money-generating business? The reasons are not far and few.
The public healthcare service in India has undergone many ups and downs. The post-independence period up to the seventies the government provided a conducive environment for the growth of public health sector. The recommendations and policies formulated by the Bhore Committee ensured that healthcare services were accessible to all. The public health sector reached its pinnacle in the sixties, but this honeymoon period did not last long. By the late seventies investments were meagre and eventually dwindling. The emergence of global recession forced the government to cut back on healthcare spending. Although, loans from IMF and World Bank helped state governments to improve the outlook of the public health sector yet they could not match up to the growth spurt of private players. Since the last decade, the situation of public health sector as a provider of primary healthcare has shown no signs of improvement and has been deteriorating rapidly. The appalling condition of public run health centers and hospitals, poor quality of service, unwillingness of doctors to serve in rural areas, non-availability of sufficient number of specialists and blatant passiveness of government has helped the private sector to capture a massive chunk of the healthcare industry. In 2012, it was estimated that the private hospital industry was worth US $25 billion and contributed to more than 50% of total beds in India. The share of private sector was estimated to be about 58% in rural and 61% in urban areas whereas government sources account for a meagre 22% in rural and 19% in urban areas (Planning Commission, 2008).
Moreover, aggressive marketing strategies and lofty promises of providing highest quality care have attracted people of all classes both in rural and urban India to the private healthcare providers. Utilization studies have shown that even the poor prefer to approach private health providers rather than availing free services at a state-funded institution due to non-availability of required services at government centers. According to the National Family Health Survey (NFHS) 3, majority of households in urban (70%) as well as rural areas (63%) choose private sector as their primary healthcare provider. Minimal intervention by the government, undesirable practices, poor quality of service, inadequate wages to professional, ineffective policies and minimal role of medical councils have all contributed to the success story of private health sector.
Although private hospitals, health centers and individual practitioners provide superlative healthcare by utilizing state-of-the-art technologies, highly skilled personnel’s and a spa-like environment yet the price demanded for these services is astronomical. Apart from the rising costs, the emergence of numerous malpractice incidents and lack of strong policies to curb such occurrences has become a matter of great concern. In a survey conducted by WHO during 2007-08, it was reported that the number of caesarean births have shot up beyond the recommended 15% – this increase was not for immediate medical need but due to financial gains. The trend of “kickbacks for referrals” has been so deep rooted in the medical fraternity that there is no prospects of its mitigation in near future. Heavy amounts are offered by the hospitals for doctors to refer a patient for angioplasty. A trivial abdominal pain during pregnancy would get referred for an ultrasound and in most cases cervical stitches will be recommended for the sake of monetary gains. It has become commonplace in several hospitals and health center to not give medical documents back to patients – a trick to avoid being legally held accountable for the unnecessary medical tests and procedures. Lately, cringe worthy incidence of diagnostic result fabrication and “sink test” have thrown the medical field in a bad light. Indiscriminate pricing of health services have pushed people to the brink of poverty and excessive financial debt. World Bank in 2001 pointed out that 40% of all patients admitted to a hospital in India have either borrowed money or sold assets which include inherited property or farmland to pay for steep medical bills.
The large presence of private sector at the primary, secondary and tertiary levels, have made them indispensable and cannot be wished away. The need of the hour is to effectively regulate this sector factoring in the complex interactions between multiple actors and their engagement with a strong political will power and leadership. Regulations are ineffective, fragmented and sporadic coupled with poor implementation. The government needs to ratify and enforce implementation at the regional level. Plugging loopholes in policies, preventing professional association from floating rules, improving the role of medical councils in policy formulation and altering incentives available to private sector institutes should be the top priority of the government. A big step in protecting the consumer rights was taken by the government by bringing medical practice under the ambit of Consumer Protection Act of 1986. Although, the Act has been effective in curbing malpractice to a great extent yet complementary measures are needed to fully reap the benefits. A lack of adequate knowledge about medical sciences has resulted in consumers placing more weight on the perceived quality, which has helped the private sector to cash in hugely. Patient education at a national and regional levels through media or campaigns can help people to make the right decisions in choosing their health provider and also identify possible malpractice attempts. For a long-term impact, public sector should collaborate with representative organisations to promote professional ethics, rational drug prescribing and conservative treatment protocols. The other major cause of rampant medical malpractice can be attributed to a lack of transparency and lackadaisical attitude of the government in implementing stringent transparency laws. According to a report by Transparency International, people below poverty line in India spend close to Rs. 10,000 crore as bribe in healthcare every year. The culture of “kickbacks” and commissions has spread like a cancerous lesion in the medical fraternity. Kickbacks should be banned and made illegal resulting in rigorous punishment to those offering and accepting such incentives. There has been a strong call for the inclusion of kickbacks in the Clinical Establishments (Registration and Regulation) Act, 2010. Lastly, a complete overhaul of the medical education system is critical. The high capitation fee demanded by almost all medical colleges brings in unmerited and knavish individuals who lack the moral conscience to practice ethical medicine. India is in dire need of selfless and service-minded doctors who can contribute to a massive extent in cleaning up the healthcare sector. All in all, a multi-faceted approach is necessary for revolutionising the healthcare system in India and the engagement of local, regional, national and global players is highly imperative.
-Dr. Mohammed T Ahmed
DISCLAIMER – The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.