Picture credit: Benjamin Hunter
Private healthcare was one of the core themes at last month’s Global Symposium on Health Systems Research, with the theme title positioning a ‘pragmatist’ support for expanded private healthcare roles against a ‘polemic’ opposition. In a special post this month we share the transcript from Abhay Shukla’s plenary presentation on the problems with such ‘pragmatic’ public-private engagement in healthcare.
The system for universal healthcare is a system which is governed by public logic. On one hand there are certain key conditions for universal healthcare which must be fulfilled by any provider which is part of that system. On the other hand is the reality of the current private sector in low- and middle-income countries.
We need socially accountable care which observes patients’ rights but what we have is a private sector which largely lacks social accountability and often denies patients’ rights.
We need observance of at least basic ethics in healthcare but we in India are seeing large-scale medical corruption.
We have a need for rational care, according to at least some basic standard protocols. What we have is what I’m calling ‘extractive medicine’ and a growing epidemic of irrational care.
We need a UHC system which will give free care to all patients, which will contain costs, and what we actually see are constantly increasing prices of care in the for-profit private medical sector and also a refusal to go for any kind of rate standardisation.
We need regulation on the content, quality and costs of care, but what we see is that self-regulation has largely failed and state regulation is being resisted.
Unfortunately many of these negative features of the private sector have not improved much, even when they are publicly paid through either public-private partnerships or health insurance schemes in India. This is a conundrum – one of the core conundrums of UHC. On one hand UHC is guided by public goals and where we say care to all, irrespective of paying capacity, and more care to those with more need. Whereas the for-profit private medical sector today is driven by a profit maximisation strategy which says more care to those who pay more. If you look at both of these together they are almost opposite, they are leading in quite different directions.
So how do we bring these two vectors into any kind of common logic? It’s a question of the square peg of private providers being put in the round hole of UHC. We need to think about this carefully, it’s not just a straight-forward fit. The private sector in countries like India is very powerful and huge, it’s not a minor player. But society, which anchors this sector, which it is supposed to serve, is much larger and much more important. Therefore society has to wake up and needs to start thinking about ‘treating’ some of these ‘illnesses’ of the private sector.
I will now try to point out a few key issues and what can be done. I don’t want this to be a purely negative presentation. There are a lot of efforts which are going on, probably in many parts of the world, and will just point out a few from our experiences. Patients’ rights denial in private sector. Basic things like right to information, right to second opinion, right to informed consent, right to reports and records, have been denied on a large scale. We’ve had a public hearing with the national human rights commission where such cases were collected. The medical councils have huge compendia of complaints in many states in India. Violations are being reported in various newspapers with very shocking cases.
Can we give public funds to a body which is not publicly accountable? I think this is core question we need to ask in the context of UHC. Any provider, whether private or public, which is receiving public funds has to be publicly accountable. In this context a positive development is that the National Human Rights Committee of India has recently adopted a Patients’ Rights Charter – these rights are listed on the website – and now the Union Ministry of Health and Family Welfare is taking these up. Patients’ rights are human rights, and they have to be observed.
Medical corruption is a growing topic of concern in India and we have this book – Dissenting Diagnosis – of which I am one of the co-authors and where we have interviewed 78 whistle-blowing doctors across India who have actually blown the lid on what is happening in many private hospitals in India, especially certain larger private and corporate hospitals. A parliamentary committee report has come out with a scathing indictment of the Medical Council of India. We have another book which has come out recently on Healthcare Corruption in India. And kickbacks are very common – one of our studies has shown 70-80% of doctors taking kickbacks.
And then irrational care. This is a growing epidemic. There is something I call pseudo-quality of healthcare – you go to a shiny hospital and there is a very nice ambience, and then your uterus is taken out, or you receive a caesarean section you don’t require. Caesarean sections rates in India are 41% in the private sector. In the public health system it’s 12%. What is going on? The indication for caesarean section is your bank balance: the higher your bank balance, the more likely you are to undergo caesarean section. Is this what we want when we move towards UHC? This has also continued into various health insurance schemes of various kinds. The Lancet series on Right Care has highlighted this paradoxical co-existence of underuse and overuse.
If it takes a thief to catch a thief, let’s turn that around and say that it takes ethical doctors to check unethical doctors, and this is something we are trying to do by developing a national Alliance of Doctors for Ethical Healthcare. Doctors from different parts of India have recently come together to form a network that is critical of the effects of healthcare commercialisation, supporting and promoting healthcare, and coming out with position papers on rational management of common conditions: when is a caesarean section required and when is it not required? When is a bypass operation, or an angioplasty, really necessary and when is it not necessary? This is a ray of hope so we can see that within the private medical sector there are also elements who are standing up for ethical healthcare.
Regulation is I think central to this issue, and I’m calling it stalled and failed. In some cases it has failed, like self-regulation, and in some cases it has stalled as there is so much resistance. There’s this whole issue of regulatory capture, nominal regulation, biased regulation, corrupted regulation and it’s become a really complex area and it’s stuck. We have a Clinical Establishments Act in India which was passed in 2010/11 but still it is not implemented in any substantial form. This kind of regulation leads to resistance from the providers and also complete apathy from the general public who don’t see anything happening. This is why we need to think about social regulation.
We have to reimagine regulation and regulators themselves need to become accountable. It cannot just become an arena of corruption. Social regulation would have a combination of state regulation; multi-stakeholder bodies which are providing oversight and holding accountable the regulatory framework, and also an element of self-regulation on the technical side by diverse medical professionals, not just one particular kind from the private sector but rather all different kinds of medical professions coming together. If we think about social regulation we might be able to re-imagine the whole scenario.
Finally, another issue I would like to flag is growing global investments and corporatisation of healthcare in India, which is also affecting other countries. The Indian model is not a great model and unfortunately we are exporting it to other countries. We are now exporting it to South Asian countries, to East African countries; our Apollos and our Fortis’. There is a larger scenario of global investment in healthcare on a very large scale. IFC, CDC and venture capitalists are getting into healthcare in a major way, and this is accompanied by the rise of corporate hospital chains, adoption of corporate practices on a large scale, and smaller providers being gradually squeezed out. These globalised financial investments are I think a very serious issue which we need to look at, and what is the impact they have on the provision of healthcare. When we are developing a UHC system we need to take a differential approach to different kinds of providers – we cannot take all of them in the same category. So how do we look at aggressively for-profit bodies like this?
There are two contending logics in the health sector in many countries: there’s a big profit logic and there’s a smaller social logic. But as we know, for UHC the social logic has to prevail over the profit logic. Some profit logic will remain, but the social logic has to become larger. This is the change that has to be ensured when we deal with the private sector. Any genuine UHC system has to treat these serious illnesses of the private medical sector. These are not going to go away on their own – public action is required. We need to decide what kind of UHC we want: public resources being used to strengthen the private sector, or private resources being used to strengthen the public system.
Abhay Shukla is a team member on Practices, regulation and accountability in the evolving private healthcare sector: lessons from Maharashtra State, India, funded by the UK Medical Research Council as part of the Health Systems Research Initiative. For more information on the project click here.