The existence of railway hospitals

In a way, Indian Railways already allows for competition. In addition to 125 railway hospitals, 133 private hospitals are recognised for treatment

Dr Robert Gillespie has a book (2006) titled The Train Doctors, A Detailed History of Railway Surgeons. This is about USA, but principles of railway development are similar everywhere in the world. “As the nineteenth century unfolded, few employers offered any kind of employee benefit packages. Workers had to secure medical care privately and at their own expense. Businesses only paid physicians to perform pre-employment physical exams or to assist them with matters of work site hygiene. 

Railroads developed into an exception to this rule, in part due to the inordinate number of injuries sustained by employees, passengers and bystanders. … Railroads initially relied on contracts with private doctors along their lines, but the huge number of visits soon made hiring dedicated railroad physicians a practical option. 

In addition, the opening of the transcontinental rail line and the subsequent westward migration brought large numbers of people to remote undeveloped areas devoid of doctors or hospitals. The western railroads had no choice but to bring in physicians and establish health care facilities. By the early twentieth century, every major railroad listed full-time doctors on its payroll.” One can understand. That’s how railways developed in India too. Consequently, IR (Indian Railways) has a huge health directorate, headed by a director general of Railway Health Services (in Railway Board), with chief medical directors in every zone and chief medical superintendents in every division.

In several railways, not just IR, health covers a range of issues, not just hospitals. But let me focus on hospitals. Here is Gillespie, not about the 19th century, but about the present. “Railway surgery fell into decline early in the twentieth century…Several factors contributed to the demise of the system. Many patients did not like being required to see designated physicians, and wanted to see doctors of their choice in their communities, especially if one lived far from a railroad hospital. Private insurance policies, prior to the 1980s, offered a wide range of choices with few restrictions. Railroad employees, through their unions, pressed for contracts with these policies in place of the restrictive railroad doctor-hospital system. Injury victims frequently asked for doctors not affiliated with the railroad. Changes in government regulations, the creation of Medicaid and Medicare, and booming medical advances in the 1950s and 1960s also made the management of health care facilities progressively more complicated and expensive. Finally, the railroads sought to divest money-losing auxiliary enterprises. As the last railroad hospitals were sold or closed in the early 1970s, the remaining railway surgeons dispersed, setting up private offices or joining other practices, although many continued to see their previous patients in the new settings.” In other words, there was market failure in the 19th century. There is no such market failure now. As long as their health needs were covered, even railway employees wanted choice, competition and efficiency.

Illustration: Binay Sinha

In a way, IR already allows for competition. In addition to 125 railway hospitals, 133 private hospitals are recognised for treatment. I thought it would be easy to find out which one of these is the oldest. It wasn’t that easy. The answer is probably Ajmer, but I am not sure. The Ajmer hospital was set up in 1890 and Kanchrapara followed in 1900. In the last piece (June 1, 2018), I wrote about railways running schools. For that, other than India, Bangladesh, Pakistan and Uganda are the only countries where railways still run schools. I don't know about the past. But today, the only countries where the railways run hospitals seem to be India, Bangladesh and Pakistan. In that Gillespie quote, you must have noticed that patients/employees wanted choice, facilitated by spread of insurance. But the moment, Railway Board explores the possibility of serving and retired railway employees being treated elsewhere, in private hospitals empaneled with CGHS/ESI, pandemonium breaks out. 

I don't think anyone contemplates closing down of railway hospitals. We are short of hospitals. Why should an existing hospital be closed down? But why should a railway employee, existing or retired, be compelled to seek treatment at a railway hospital, if an alternative exists? That idea of treatment in empaneled government and railway hospitals isn’t new at all. What’s the bed occupancy ratio in government hospitals in India? Around 95 per cent. What’s the bed occupancy ratio in railway hospitals? I have some old figures of 62 per cent. Given our shortage of hospitals, this means railway hospitals are not optimally used. Why should non-railway patients not be allowed to access railway hospitals? Why do we have this fuzzy dividing line between railway and non-railway patients and railway and non-railway hospitals? A hospital is a hospital. This leads to the next question, which explains the pandemonium. Why do railway hospitals have to be under railway management? That turf battle and desire to control is the real reason behind the resistance. That’s the reason IR (Indian Railways) can’t concentrate on its core business, which is that of running trains.

Here is a quote about corruption in the railway hospital in Jhansi, from ipaidabribe.com. “The Doctors and other employees in the Hospital take bribe from employees for sick certificates. Employees who are not really sick pay bribes to get false sick certificates. Employees pay for getting Medical Fitness Certificates. Even poor patients cannot get good treatment, if they don’t bribe.” Of course, it happens elsewhere too, in non-railway hospitals. But is this the reason those in IR don’t went to change the status quo?

The author is chairman, Economic Advisory Council to the Prime Minister. Views are personal