Sunday, December 17, 2017
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Government health system expands and begins to provide quality care. Source: Wikimedia Commons

Roping small private players, charitable institutes and general practitioners into public healthcare system can help compete with corporate hospitals

THE RECENT incidents of medical negligence and over pricing have spurred strong criticism of private players with Delhi government cancelling the licence of one hospital. What escapes the eye, however, is the constant support since 1990s that has led to growth of private sector at the cost of affordable government or public healthcare. 

This has also pushed the vast majority of doctors passing out from medical colleges towards 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.

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 due to its profiteering linked with complete lack of regulation This is compounded by the exploitation by pharma industry through manufacturing and sale of irrational medicines and irrational drug combinations, costly brands and overpricing.

Rise of private sector has been concurrent with massive wastage, irrational medications, overcharging and major variations in quality

Added to it during the last 20 years there has been proliferation of private medical colleges and unregulated medical equipment industry. 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). 

Public funds in private care

If government health system expands and begins to provide quality care to a large portion of the population, the private sector would have to respond appropriately. 

However, since such major expansion of the public health system would take some period of time and resources, the government advocates models like public-private partnerships where public funds would be handed over to the private medical sector without any effective regulation or accountability and in a manner that would further weaken the public health system.

We need to develop instead, 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) to strengthen and complement the government health system. 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. A section of such providers will have to be contracted into public health systems in significant numbers, at least for urban areas. 

To achieve the requirement of shortage of doctors in public sector, health providers will have to be contracted into govt healthcare in high numbers 

The contracted doctors would be so regulated that they conform to scientific, ethical medicine in tune with the logic of social medicine. As in case of the original National Health Service model in Britain, insourced private practitioners would then remain private only for the name’s sake.

Insource facilities of charitable hospitals 

Historically, India enjoyed 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. Such facilities face their own share of problems due to the larger pressure of market-driven health care, especially its negative influence on doctors.

Many small and charitable hospitals face their own share of problems due to larger pressure of market-driven health care

Such facilities should be identified 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. 

We have a very large number of general practitioners running their small individual clinics. Currently, they are 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, they could be contracted into the publicly managed system by the state especially in urban areas.

The general pracitioners can be contracted into the government healthcare system  

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. 

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. 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.

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. Since leaving provision of these free beds to the hospitals themselves is open to manipulation, these 20% free / low cost beds should be insourced into the public system, and managed as public resources.

Regulate big corporates

These corporate hospitals will have to be regulated even if all of them remain outside the universal public 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.

Progressive control over medico-industrial complex with internal democratisation should be the direction for corporate healthcare 

Trade unions or associations of employees of such staff, wherever they exist, could be an ally in demanding regulation of private medical facilities.

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. 

At the same time the Act needs to be made universally applicable in all states. Detailed framework of patients’ rights must be included in state rules that 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.

Combined with monitoring by relevant authorities, there is need for community based monitoring as well.

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

 

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