Regulate the private health sector

Like telecom, power, and aviation, we need a regulatory system for health care at all levels

The successful expansion of the private health sector in India has been a matter of justified pride but also of much despair. Many private hospitals have achieved success in delivering speciality services — be it cardiology, oncology, complex surgery or transplanting organs — to name just a few. Sophisticated diagnostics have revolutionised medical treatment at a fraction of the cost of treatment overseas. Even so the general impression prevails that private establishments are often unethical, greedy, treating medical service as a business and hospitalisation as a source of profit. What hurts citizens most is the virtual absence of regulation of almost everything that happens — standards, quality, costs — and the absence of an ombudsman.

The private health sector, unlike IT, is not a man-made wonder but the outcome of several economic liberalisation policies. Successive governments (finance ministry) donned the mantle of a facilitator, but without first establishing a regulatory mechanism to oversee malpractice. The private health players were conferred the status of industry which opened access to cheap, long-term loans; followed by 100 per cent automatic Foreign Direct Investment (FDI) from 2000 onwards and a near doubling of the cap on FDI in health insurance the sector boomed.Alongside Customs duty on medical equipment was slashed from 100 per cent prevailing in the eighties to the present 7.5 per cent. Land was given at heavily subsidised rates, in some cases as in prime locations in Delhi at Rs 5,000 an acre and a virtually absurd Rs 1 for 15 acres-to a joint venture with the Delhi government.

Frequently the concomitant requirement of providing free medical treatment to an agreed proportion of patients from the economically weaker sections was ignored. Binding contracts were circumvented ending in protracted litigation. CAG has recently reported on “unjustified exemptions” and how Trust and Charitable hospitals in Mumbai have skirted binding obligations towards the weaker sections.

Although the private sector accounts for 80 per cent of out patient care and 60 per cent of in patient care in the country speciality hospitals have a presence only in the metros and other major urban centres. The bulk of the Indian districts have no private hospitals while innumerable single practitioners run thriving businesses. NSSO (67th round) shows that the number of establishments run by single medical service providers far exceeds establishments engaging even a workforce of 10. These one man enterprises account for nearly 80 per cent of all medical establishments surveyed and are run by allopathic, Ayurvedic, Homeopathic practitioners but overwhelmingly by persons whose highest qualification is at school level- possessing no recognised medical qualification whatsoever. 

At the bottom of the country’s totem pole come over 700,000 villages whose inhabitants are expected to visit Government sub centres managed by an auxiliary midwife (ANM,) for health care. An ANM is however not authorised to stock or prescribe drugs needed for acute illnesses. The Government doctor (if he is available) is located in a Primary Health Centre some 5, 10, even 15 kilometres away from hundreds of villages in that taluka, there being less than 30,000 PHCs in the whole country. A rickshaw puller, an agricultural or construction worker — for that matter anyone on a daily wage- has perforce to go to an unqualified practitioner (UMP)-commonly called an RMP- faced with a sudden or acute illness.The opportunity cost of going to a qualified doctor involves foregoing the day’s  wages and facing unforeseen expenditure on transport-quite simply unaffordable; especially when a single transaction with a nearby UMP can usually provide relief at the cost of a few rupees. 

NEED FOR OMBUDSMAN: What hurts patients the most is the absence of regulation in things such as standards, quality, and cost

Several central laws prohibit medical treatment by anyone except a doctor. Paradoxically, all studies have shown that it is qualified doctors who pay handsome commissions (30 per cent of the fees) to unqualified practitioners for making referrals to them; they have in fact employed and trained these helpers to administer injections, IV fluids, antibiotics and steroids. A WHO (2016) analysis reveals that India has more unqualified practitioners than qualified doctors. In the absence of enforcement, UMPs stock and treat with strong medicine often as demanded by the patient. As a result of incompetence and commercialisation here and elsewhere, multi-drug resistant TB, failed antibiotic treatment and the irrational use of fourth generation drugs have become a reality. 

In India the citizen — rich or poor — has virtually no protection against medical exploitation or malpractice. Regulators like the Medical Council of India and the State Medical Councils rarely react to medical malpractice.The Consumer Protection Act 1986 deals with the failure of service contracts — the focus being on compensation and not medical malpractice which is the crying need. Incidentally public sector doctors are not covered even by such controls.

In 2010 the Central Government enacted the Clinical Establishment Act 2010 to register and regulate all health establishments, their standards, the qualifications of the workforce with the stated aim of ending quackery. Not a single state has actually adopted the Act by establishing a regulatory structure capable of enforcing either standards or quality. More than half the states do not even have a legislation requiring private establishments to be licensed. Those that do have some kind of legislation like the Delhi Nursing Homes Act 1953 still retain a token penalty of Rs 100 for a transgression.

Technological and regulatory oversight have controlled the private sector in telecommunications, electricity, civil aviation and corporate enterprise. A host of Authorities, Boards, Commissions, Tribunals and Appellate bodies have exercised the power to supervise and enforce. Treating and saving human lives is obviously a larger imperative by far. Needed is a regulatory system to oversee the health sector at all levels –public and private. It is now a matter of compulsion.

The writer is a former secretary in the health ministry