A cure for India’s health care ills is within reach provided there is political will
In most developed — and many developing — countries today, a 12-year school education and universal health coverage (UHC) are the two primary responsibilities of the state. India has failed miserably on both counts. Let us look at some of the problems of medical and health care:
• Fifty years ago, when there was no commercialisation of medicare that we have today, we had only government hospitals or those run by trusts as public service. There weren’t enough of them but they provided excellent medical and health care (medicare) by dedicated professionals. Today, the government hospitals are a shambles.
• Medicare of reasonable quality is currently largely commercialised and corporatised, the primary objective being to get the maximum money from patients by giving them the minimum possible in return. The irony is that while the average quality of health care provided by commercial hospitals is far from satisfactory, we have in them, taken altogether, world-class expertise in virtually every field of medicare. Therefore, you can get the best possible medical attention in our country if you have unlimited money.
• Many commercial hospitals in the country have been given land at concessional rates and exemption of duty on imported equipment, on the condition that they would treat a certain percentage of poor people free. However, there may not be even one hospital that meets this obligation.
Quality of education
• The quality of medical education — barring in a handful of elite institutions — has progressively gone down. Till recently, recognition by the Medical Council of India (MCI), the accrediting body for medical colleges, was based not on the ability of the proposed institution to provide quality education but its ability to pay the Chairman of MCI (one of whom has been jailed) and members of the inspection team. This expense was more than recovered by the capitation fee charged for admission in the medical college, and a guaranteed degree irrespective of ability or performance.
• The system of general physicians (GPs), which is the backbone of the National Health Service in the United Kingdom that provides one of the best UHC in the world and which was also the backbone of our medicare system when we became independent, has virtually disappeared. Till recently, no medical college provided an MD course in family medicine. After I gave the convocation address at the West Bengal University of Health Sciences a few years ago, the government of West Bengal, with the support of Gopal Gandhi, then Governor of the State, his Health Minister, and the university Vice-Chancellor, decided to introduce an MD course in family medicine. This may, however, be the only one of its kind.
Consequently, today, it is the (often ignorant) patient who decides which specialist to go to, even for the most trivial of problems. The specialist — in most cases, in the private, commercial sector — finds a disease of his speciality, even when it does not exist. Moreover, he is generally too busy to ask his patient if he has any other problem or is taking any other drug besides that prescribed by the specialist. We thus had a case in Hyderabad when a person chose to go to seven specialists, each one of whom prescribed him a course of antibiotics; he returned to the hospital as a victim of antibiotic toxicity. The fact is, unlike a specialist, a family physician (a GP) cannot recover the astronomical amount spent on getting admission to a medical college.
• Many private commercial health care establishments have touts in villages who bring them patients against a commission. This was once recorded in a sting operation in Hyderabad and reported by us to the State Medical Council that did nothing about it.
• Unnecessary diagnostic tests (for prescribing which a doctor gets commission from the diagnostic laboratory), surgical procedures and stay in the hospital, are common practices resorted to by commercial hospitals.
• Payoffs to doctors for recommending a particular test to be done in a particular diagnostic centre, or for recommending another doctor or hospital, are rampant.
• There are also payoffs today to doctors in private hospitals. For example, in a private hospital in Bhopal that was ostensibly set up to take care of the gas disaster victims, Rs. 2.81 crore was paid to 30 doctors in the hospital over and above their salary which was substantial, between 24.07.2010 and 31.01.2012, out of the money received from private patients, according to the data provided by the hospital itself under the RTI Act.
Neither fair nor transparent
• The billing of patients in private hospitals is often neither fair nor transparent. I had the personal experience of having a bill presented to me at the time of getting my wife discharged from a corporate hospital in Hyderabad, in which the charges for anaesthesia (couched in a language that did not make sense) were included even though my wife was not administered any anaesthesia.
• The right of the patient to have a copy of his medical record is often not respected.
• There is no legal imperative today for a hospital, diagnostic centre, or infertility clinic, to be registered and accredited. Through the efforts of The MARCH (The Medically Aware and Responsible Citizens of Hyderabad, an organisation which has met every month in Hyderabad since September 1995), our country has a system of voluntary accreditation of clinical laboratories; this must be made mandatory. Similarly, through another initiative taken by The MARCH nearly a decade ago, we today have a bill for accreditation and supervision of infertility clinics ready to be placed before Parliament. None of the problems, for example, relating to surrogacy, that we have been reading in the press recently, would have arisen if the provisions of the bill had been followed. And very few hospitals in the country are accredited under the National Accreditation Board for Hospitals as such accreditation is voluntary.
• It appears that 10-25 per cent of the drugs in the market are spurious or of low quality. The sources of such drugs are often known but nothing is done about them.
• There is a nexus between drug companies and doctors who benefit substantially in cash or kind for prescribing a drug made by a particular company, even when cheaper or better alternatives are available.
• There is no obligatory requirement for all registered medical practitioners to go through continuing medical education courses (CMEs), to keep themselves updated in their area of expertise.
• The course we used to have on medical ethics in our medical colleges has been abandoned. Therefore, ethics is not a word in the dictionary of most of our doctors.
• We need an appropriate code for medical shops which, for example, should not be allowed to act as general stores or sell scheduled drugs without a prescription.
• Terminally ill patients should be allowed to die in peace with as much comfort as possible. There are very few establishments in the country for palliative care of such patients.
• Many of the clinical trials in this country ignore the ethical code — even the legal requirements — for clinical trials for which India is a key destination world-wide.
• There is virtually no impartial market surveillance after the release of a new drug.
The consequence is that India is the world capital of malnutrition, stunted growth, infant and child mortality, burden of disease, and indebtedness on account of (often futile) out-of-pocket expenses on health care. A fair proportion of farmer suicides in the country out of over 250,000 during the last decade or so, have been on account of inability to pay money borrowed at exorbitant rates of interest for health care.
The solutions to the problems mentioned above are obvious and well within our capabilities and resources if we have the political will. For example, the implementation of the excellent report (The Hindu, April 14, 2012) of the High Level Expert Group set up by the Planning Commission for working out modalities of UHC, under the Chairmanship of Dr K. Srinath Reddy, will take care of several major problems mentioned above. Dr. K.K. Talwar, present Chairman of the MCI and president of the National Academy of Medical Sciences, recently set up a high-power committee under the chairmanship of Dr. Nirmal Ganguly (former Director-General of ICMR) to work out a code of ethics for medicare establishments and related organisations. We hope that the report of this committee will give us a framework for solving many other problems that have an ethical angle to them.
(Pushpa M. Bhargava is former Vice-Chairman, National Knowledge Commission.)