Thursday, March 27, 2014
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There's still hope if we care to promote private practitioners without weakening public sector
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. 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.

 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.

In the last post, we talked about how public funds are getting parked into the care of the corporates. This is why we need comprehensive regulation of private medical sector.

Complimentary treatment needed 

Certain contracted private doctors and facilities should act as an extension of the public health system by following appropriate guidelines. However we need to keep in mind that so far in India, much of the interaction between the public health system and private providers (often labeled as ‘Public-private partnerships’) has been deeply problematic. 

In most of these models, while public funds are handed over to private providers, their mode of functioning has not been brought in line with public health logic, and they may even tend to replace or weaken public systems. We need to envisage a qualitatively different form of interaction, where certain private facilities are contracted and given a more public character to fill gaps and complement and strengthen the public system. But for this to occur, the terms of engagement with the private providers should be clearly formulated. 

Establishment of a strong regulatory structure with oversight by bodies including community and civil society representatives should be a pre-condition for any interaction between the public health system and private providers. The regulatory framework should be participatory and should encourage self-regulation. 

Establishment of a strong regulatory structure with oversight by bodies including community and civil society representatives should be a pre-condition for any interaction between the public health system and private providers. 

Secondly, all such providers will have to respect, observe patients’ human rights and should have adequate, just grievance redressal system. All publicly funded services should be regarded as a form of public service in terms of their accountability obligations – such as respecting right to information, allowing community-based monitoring, and regular reporting to various public bodies.

Bandaging the private parts

To move towards engaging the private sector in a much larger scale, we need to win over a section of private (including not for profit) health care providers around the need to move towards health care for all, and to neutralise other sections of these providers who would for reasons of vested interests would otherwise have opposed it. 

The range of private and non-public providers in our country is extremely diverse and even bewildering, and we cannot paint all of them with the same brush, in either black or white. We would need to take a differential approach based on how much amenable each section is to some degree of socialisation.

i) Non-profit health care

We may keep in mind that historically we have a significant section of charitable, mission and not-for profit health care facilities, many of whom are working in less developed, rural and remote parts of the country. Many of the hospitals and smaller facilities involved with networks like CHAI and CMAI as well as many NGO-run health facilities would fall in this category. Such facilities today face their own share of problems due to the larger pressure of market-driven health care, especially its negative influence on doctors.

Many of the hospitals and smaller facilities as well as many NGO-run health facilities face their own share of problems due to larger pressure of market-driven health care, especially its negative influence on doctors. 

Such facilities should be identified based on sturdy criteria (including proportion of patients treated free and range of rates charged for standard services) and prioritised for inclusion in the healthcare for all system. With provision of certain level of public funds, they would be able to function much more effectively and could fill certain critical gaps as well as provide a model for other private providers. 

Beyond the more or less genuine not-for-profit providers, there are large numbers of hospitals which have been registered as trusts to gain public subsidies and income tax exemptions, however they may not necessarily function in a charitable manner as per their declarations. While massive public subsidies,including cheap land in prime urban areas, have been availed of these facilities, they often do not provide the mandatory 20% free / subsidised beds to poor patients, and this has been an issue of court orders and social demands. 

This can be done by pinning them down to their declared objectives in the Trust Deed through participatory monitoring and effective redressal mechanisms. The current practice of indulgence in money-making and yet showing no profits in the balance sheet can not be continued.

Since leaving provision of these free beds to the hospitals themselves is open to manipulation, these 20% free / low cost beds (these number in tens of thousands of prime hospital beds across the country) should be mandated to be insourced into the public system, and managed as public resources in conjunction with the public health system. Any ‘trust’ hospital refusing to fulfill this obligation should be required to pay compensation not only for massive subsidies availed, but also retrospectively for all the free care that has been denied by them to poor patients since years and even decades. 

This measure would make available significant additional resources to the public health system which could fill gaps especially related to secondary and tertiary care in urban areas.

ii) General practitioners

In India, we have a very large, numerically predominant section of general practitioners running their small individual clinics. In this ‘unorganised’ sector, the private practitioners are like other middle class professionals who sell their services to people. 

We need a strategy about these clinics as well. Currently, they are subsumed under the logic of market, being sucked in as agents of the medico-industrial complex and indulge in commercial exploitation of patients. Their practice should be regulated as regards their location, quality and pricing. Secondly, the regulated doctors required for universal health care could be contracted in sufficient numbers into the publicly managed system by the state (for example, as in case of the original NHS in UK) especially in urban areas.

The regulated doctors required for universal health care could be contracted in sufficient numbers into the publicly managed system by the state (for example, as in case of the original NHS in UK) especially in urban areas. 

With proper contracting and regulation, the private clinics would then remain ‘private’ more or less nominally. Here too, the basis for involving such practitioners would be to fill existing gaps in the public system (which are major for example related to outpatient care in urban areas, where the private sector largely dominates).

Insourcing of individual specialists to public hospitals which have major vacancies of specialists also needs to be pursued much more systematically with elimination of bureaucratic obstacles and corruption in such insourcing, which can significantly strengthen the services of public hospitals. 

iii) Small private hospitals

Next, the position of small and medium sized private hospitals is contradictory, since on one hand they tend to function more in an ‘investment-profit making’ mode, on the other, with expansion of corporate and large hospital dominated chains, they are feeling the pressure of being pushed out of the market. 

Discussions with small hospital owning doctors especially in some cities show that they are beginning to seriously feel the compulsion of having to compete with the big corporate / private hospitals which often offer more ‘amenities’ and have glamour value for patients, and offer higher ‘cuts’ to referring doctors. Further removal of user fees, free drugs and improved quality of care in public hospitals would undermine their position in the market. Keeping this in mind, their involvement should be actively undertaken through clear contracts which specify the package of services they would provide but ensuring proper regulatory and monitoring systems in place.

Regulate big corporates

Finally, corporate and large private hospitals are because of their very nature, least likely to positively respond to any genuine health care system where the leadership is with the public health systems. Most of the members of this section would be least amenable to serve social goals and are least likely to be part of a genuinely regulated universal healthcare system. The strategy towards this sector would depend upon balance of socio-political forces. 

In any case, these corporate hospitals will have to be regulated even if all of them remain outside the universal healthcare system. An unregulated corporate sector would adversely affect the overall culture in the health care no matter that it serves only the rich. Progressive social control over the medico-industrial complex with internal democratisation should be the direction we should advocate. Actual progress in this direction depends upon level of political pressure that can be generated towards this end.

An unregulated corporate sector would adversely affect the overall culture in the health care no matter that it serves only the rich. Progressive social control over the medico-industrial complex with internal democratisation should be the direction we should advocate. 

Further, it may be kept in mind that the internal functioning of all private facilities would have to be democratised – the doctors including duty/resident doctors, nurses and other staff working in these hospitals should have adequate say in the functioning of these hospitals and their democratic rights should be respected. Trade unions or associations of employees of such staff, wherever they exist, could be an ally in demanding regulation of private medical facilities.

Read the first part of this series Tying the knots of health care system

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

 

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