Monday, January 6, 2014
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Public institutes need to insource talent and resources from private sector and shun partnership model
Noble profession: Nurses adjusting a doctor's mask in Calcutta during World War II. Source: Cecil Beaton/Wikicommons

India’s health care system is one of the most privatised in the world. Thanks to policy of the government to encourage the growth of the private sector, especially since the 1990s, the share of private sector in various components of health care in India today is very high.

Due to insufficient expansion of the public health system and overall private sector friendly policies of the state, the vast majority of doctors passing out from medical colleges have joined the private sector. This trend has accelerated with production of higher proportion of postgraduate doctors since the 1970s.

In 1950 there were 60,000 MBBS doctors, now there are 7.5 lakh MBBS, equal number of AYUSH doctors and most of them are private providers. Added to this is the tremendous growth of corporate hospitals, starting with the Apollo Hospital in Chennai in 1983.

Corporates in pink of health

The neo-liberal policy has fuelled the growth of corporate health care from 1990s. As per Centre for Monitoring Indian Economy, during 2003-2008, sales of 30 companies in healthcare sector have galloped. For example that of Apollo Hospitals Enterprise Limited increased from Rs 500 crores to Rs 1,458 crores in this period. In 2008, the income of Apollo Hospital alone was of Rs 1,150 crores, 28% more than previous year’s and profit was Rs 102 crore, 51% more than previous year.

Despite its rapid growth and large size, the private medical sector in India suffers from a wide range of serious problems and it is widely acknowledged that these arise due it’s profiteering linked with complete lack of regulation This has led to huge urban-rural divide, massive wastage, exploitation due to excessive/irrational medications, frequent exploitation of patients by overcharging and unnecessary interventions, major variations in quality and overall substandard care, violation of patients’ rights. This is compounded by the exploitation by pharma industry through manufacturing and sale of irrational medicines and irrational drug combinations, costly brands, overpricing.

Rise of private sector has been concurrent with huge urban-rural divide, massive wastage, excessive/irrational medications, overcharging and unnecessary interventions and major variations in quality and overall substandard care

Added to it during the last 20 years there has been proliferation of private medical colleges and unregulated medical equipment industry. Thus overall barring some centres of excellence, private medical care in India is substandard and unnecessarily costly. There has been complete failure of regulatory agencies like the Drugs Controller, the Medical Council of India not to speak of complete lack of self-regulation by the professional bodies like the Indian Medical Association (IMA). Starting from this background of present overwhelming presence of private health care in India, it would be quite a task to reach the goal of health care for all. 

Today most people have to pay to access health services and still have no assurance of quality and rationality of care. Moving ahead from this situation, we have to envision a process through which we can achieve the goal of 'Health Care for All'. While this would involve massively expanding, strengthening and reorienting the public health system, given the majority of health care resources today under sway of the private sector, this sector cannot be ignored or wished away. 

In fact even expansion and improvement of the public health system is in some ways linked with reshaping the private medical sector, since key aspects such as availability of doctors, legal or illegal private practice by public doctors, referral patterns etc. are linked with current dominance of the private sector. In context of such a broader framework, we need to think about how to deal with the massive private medical sector, keeping in mind its current serious problems, as well as the large scale health care resources that are currently under its sway.

Improvement of public health system is linked with reshaping the private medical sector, since key aspects such as availability of doctors, legal or illegal private practice by public doctors, referral patterns etc. are linked with current dominance of private sector

Public funds in private care

If the public health system expands substantially and begins to provide quality care to a large portion of the population, the private sector would be put in a situation where it must either function in a more responsive manner or become progressively irrelevant. 

However, since such major expansion of the public health system would take some period of time, and even to enable such expansion in the near future, resources such as specialist doctors have to be reclaimed and the influence of the private sector has to be rolled back, we need to decide how to deal with the existing private medical sector. In this context, two diametrically opposing approaches are available to us today:

  • Either public resources would be made to serve private benefit, or 
  • Private resources be made to serve public benefit.

The choice between these two approaches is one of the core contentious issues that lies at the base of current debates about universal healthcare in India. Today a dominant strand in the establishment is advocating the former approach under the rubric of publicly funded health insurance schemes and certain variety of ‘Public-Private partnerships’, where with amplification of certain existing models, large scale public funds would be handed over to the private medical sector without any effective regulation, accountability or rationalisation of this sector, and in a manner that would further weaken the public health system.

Establishment is advocating the models where large scale public funds would be handed over to the private sector without any effective regulation, accountability or rationalisation, and in a manner that would further weaken the public health system

We need to develop the alternative approach of using sections of private resources for public benefit. This would involve in-sourcing of certain kinds of private providers (including not for profit providers) in a manner that would strengthen and complement the public health system instead of weakening it, using such providers where and if necessary and under certain terms and conditions.

In urban India, about 5 lakh doctors would be needed in coming 5 to 10 years to achieve the goal of one doctor per thousand population. Currently, only about 60,000 doctors are employed in urban public health centres since around 95% of medical specialists are in the private sector.

To achieve the requirement of around 4.5 lakh doctors in public sector we would need a ten-fold increase in the public health system in next 5-10 years. Even if special efforts are made to recruit doctors and new medical colleges are opened, most of them are likely to continue in various forms of private practice. A section of such providers will have to be contracted into public health systems in significant numbers, at least for urban areas, regulated by certain terms and conditions. 

To achieve the requirement of around 4.5 lakh doctors in public sector health providers will have to be contracted into public health systems in significant numbers, at least for urban areas, regulated by certain terms and conditions in tune with the logic of social medicine. 

Such contracting-in would have to be based on appropriate regulations and guidelines. The contracted doctors would be so regulated that they conform to scientific, ethical medicine in tune with the logic of social medicine. In a socially regulated system, the scope for commercial cheating and exploitation by individual practitioners would be eliminated, and in fact, as in case of the original NHS model in Britain, insourced private practitioners would then remain private only for the name’s sake.

Precautions for all 

Comprehensive regulation of the private medical sector in India is absolutely essential. The current Clinical Establishments Registration and Regulation Act lays down certain very broad guidelines for regulation, and it has currently been adopted by only a few states. On one hand, the Act needs to be broadened since it does not mention the principles of patients rights nor does it ensure public health obligations of private providers. Such reformulation should be based on a consultative process, to take into account the concerns of various stakeholders including health rights organisations and patients groups, so that no serious lacunae remain. 

At the same time the Act needs to be made universally applicable in all states. The national rules under the current Act have now been formulated, hence corresponding rules need to be adopted by states. Detailed framework of patients’ rights must be included in such rules. Further, the rules should include specifying a decentralised framework of implementation by an autonomous regulatory authority guided by multi stakeholder bodies (including civil society organisations working on health rights) to promote and monitor the regulatory work.

The government claims that the Clinical Establishment Act 2010 would serve this purpose of regulation of private providers. Unless an effective, adequate regulatory authority is put in place, with the structure to implement the regulations, the talk of regulation would mean only empty words. 

Government claims that the Clinical Establishment Act 2010 would serve the purpose of regulation of private providers. Unless an effective regulatory authority is put in place, with the implementing structure, the talk of regulation would mean only empty words. 

Appropriate agencies/structures would be required to operationalise regulation and standardisation. Health care authorities at various levels for direct implementation of regulation and health boards or councils at various levels with representatives of various stakeholders meeting periodically and carrying out broader planning, decision making, standard setting and monitoring of regulation.

Combined with monitoring by relevant authorities, there is need for participatory monitoring (on the lines of community based monitoring) by multi-stakeholder bodies that may be similar to health councils in Brazil. Further a user friendly, independent, redressal mechanism at local level is needed which will have to be widely publicised.

To be concluded...

This content was provided by Jan Swasthya Abhiyan (People's Health Movement).

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