Healthcare systems need drastic surgery

High-end private healthcare in India has recently taken a couple of hard knocks. The West Bengal Clinical Establishment Regulatory Commission, set up in response to widespread public protests over mistreatment and overcharging, has in an early verdict fined Apollo hospital chain ₹30 lakh over the death of a 4-month-old at their Kolkata hospital for “mismanagement and misrepresentation”. The hospital will appeal.

Most recently, the Maharashtra FDA (Food and Drug Administration) has sent to the National Pharmaceutical Pricing Authority a report on startling overpricing of medical devices by leading hospitals. In an obvious attempt to get around the regulator’s cap on the price of coronary stents, these hospitals are levying a huge markup on balloon and guiding catheters also used for angioplasty. If you add the margin that the distributor makes, patients are paying five times the imported cost of these devices. The latter already includes the development cost and the margin of the manufacturer.

What is the way out so that even those who can pay (most going to private hospitals pay more than what they afford) are not fleeced and made victims of incompetence? As early as five years ago, the WHO representative in India had sought regulation of the private healthcare sector represented by “five-star” hospitals.

Not only has such regulation been slow in coming (the West Bengal law came after all private healthcare stakeholders opposed it tooth and nail), it is doubtful as to how effective it will be at the end of the day, given India’s bureaucratic culture. Even if justice comes, it is likely to be hugely delayed, going by the backlog in consumer courts and RTI forums.

A clue to what can work was contained in the other part of the WHO representative’s prescription — tax based financing of universal health coverage. This, along with a degree of regulation of private delivery can achieve something meaningful.

The fundamental point is that so long as there is a massive shortfall in state delivery of affordable healthcare, people will be forced to turn to private deliverers who will be prone to overcharge and underserve.

On the other hand, in geographies where the public health service is both somewhat adequate and of reasonable quality, private healthcare prices are relatively lower than elsewhere. The situation in Kerala, for example, is partly influenced by this as also the fact that there are many private non-profit hospitals run by religious orders.

Obviously, for public health service to get anywhere, government funding for it has to increase sharply. (Over 80 per cent of what Indians spend on healthcare is out of pocket and in 2016-17 state and central governments spent 1.4 per cent of GDP on health compared to a global average of 5.99 per cent.)

This is stated most often but, difficult as it is to find the tax resources, that is really the easier part. The far greater challenge is to improve the quality of management of the public health service so that enhanced funding translates into at least somewhat acceptable delivery.

A senior doctor who has had exposure to both public health administration and private healthcare post retirement says that it is imperative for State governments (health is a state subject) to have a “health policy that lays down priorities.” In this it is critical to lay the maximum stress on primary healthcare and the effective functioning of primary health centres.

The health policy released by the Centre this year gets it right by prescribing that two-thirds of spending will go to primary healthcare but this must translate into there being functioning primary health centres across the country which have doctor and paramedics in attendance and a stock of essential medicines to distribute.

As opposed to this, ministerial pronouncements most often dwell on the setting up of new super speciality hospitals as a sign of taking adequate healthcare to the masses.

Next comes the sub-divisional hospitals. The legendary 80-plus Sitanath De, an FRCS who has spent a lifetime in a small town delivering highly affordable healthcare, says the situation today is not what it used to be.

A lot of investment has been made in equipment but there is often an issue with staff being posted to run them and their regular maintenance. So despite the facilities being there on paper, usage is often low. This is a simple management or administration issue.

Now we come to district hospitals. The cardinal reality in India is that the national doctor patient ratio is poor compared to international benchmarks, but the ratio for rural areas is worse.

This is because doctors are reluctant to move out of urban areas. The solution suggested is to make district hospitals into teaching hospitals where a preference is given to local students so that on becoming doctors, they will be ready to work in areas where they come from. Rural areas also face a severe shortage of paramedics. There are two related ways of addressing the across the board shortage of skilled people. Have more nursing colleges and train not just nurses but also what developed countries call “nurse practitioners” who can deliver basic diagnosis and prescribe essential treatment.

The MBBS lobby has been against nurses prescribing drugs. Two-year courses for nurse practitioners in critical care have been started. A group of secretaries has recommended that nurse practitioners be allowed to prescribe essential medicines after completing a bridge course.

The current reality is that in the absence of a sufficient number of functioning primary health centres, the secondary and tertiary hospitals are burdened with patients who do not need to come to them at all. Another reality is that most poor people go to the chemist instead of the doctor, describe an ailment and ingest medication recommended by medicine shop assistants who are not even trained chemists. Nurse practitioners can go a long way in filling these gaps.

The writer is a senior journalist

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