Like telecom, power, and aviation, we need a regulatory system for health care at a 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 specialty 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 percent 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 circum-vented 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 work- force 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 illness- es. The Government doctor (if he is available) is located in a Primary Health Centre some 5, 10, even 15 kilometers 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.
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, IVfluids, 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 con- tracts — the focus being on compensation and not medical malpractice which is the crying need. Incidentally public sector doc- tors 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
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हिंदी समाचार बुलेटिन: बच्चों की मौत का बढ़ता आंकड़ा
Unqualified Medical Practitioners In India – The Legal, Medical and Social Dimension of Their Practice
Main Building, India International Centre (IIC), Lodhi Estate,
on 24th July 2017
Introduction by Shailaja Chandra, Former Secretary Government of Indian and author of a recent book on the subject
Panelists: Dr. Ramanan Laxminarayan, Princeton University; Dr Amit Shovan Ray, Professor of Economics, Jawaharlal Nehru University; and Dr. Anand Krishnan Professor, Centre for Community Medicine, AIIMS New Delhi
Chair: Dr. Dipankar Gupta, former Professor of Sociology at Jawaharlal Nehru University
|HEALTH TALK “Unqualified Medical Practitioners In India – The Legal, Medical and Social Dimension of Their Practice”
Introduction by Shailaja Chandra,Former Secretary Government of Indian and author of a recent book on the Subject
|Dipankar Gupta was formerly Professor in JNU’s Centre for Social Systems and affiliated to leading Universities in the US, Canada and France. Among non-academics he is better known as a public intellectual and opinion- maker who continues to write regular opinion pieces on critical issues of contemporary significance. He has been a member of the Boards of Reserve Bank of India and of NABARD|
|Introduction: Shailaja Chandra is generally introduced as the former Chief Secretary of Delhi. But much before and after that she has had a long policy level association with public health, medical education, population stabilisation and Indian medicine.
She is the author of a Status Report on the Indian systems of medicine and a strong proponent of integrative medicine for public benefit. She was the first Executive Director of the National Population Stabilisation fund.Ms Chandra has been a fellow at the Institute of Advanced Studies at Nantes, France and more recently at the Shiv Nadar University.
|Mr C K Mishra Union Health Secretary, Ministry of Health & Family Welfare|
|Panelists: Ramanan Laxminarayan directs a Center for Disease Dynamics, Economics & Policy and also teaches at Princeton University. With experience of working in WHO, the World Bank and CDC Atlanta he brings the unique perspective of an international epidemiologist and a drug resistance economist. Notably he was a TedMed Speaker in 2014 and his talk focused on growing drug resistance an aspect which is directly related to the subject of medical treatment by unqualified practitioners.|
|Panelists: Amit Shovon Ray is a Professor of Economics at the School of International Studies at JNU and a Fellow of the Royal Society of Public Health (UK). He is a development economist and an expert in the areas of health economics, IPR and pharmaceutical industry. Of special relevance to today’s Seminar are his contributions to the Independent Commission on Health in India and in particular his critiques of the functioning of the health sector. Professor Ray has published on a range of subjects but his work on medicines, medical practice and health care in India as well as the political economy of rural health care in the country make him eminently suited to comment on today’s subject.|
|Panelists: Professor Anand Krishnan is a faculty member at the Centre for Community Medicine at AIIMS for last 23 years. He heads the WHO collaborating centre for community based control of non- communicable diseases and has worked closely with WHO in supporting many countries in the region like Bhutan, Nepal, Maldives, Myanmar, Srilanka, East Timor in strengthening their national NCD Surveillance and response. He also steers a large research grant from CDC Atlanta focused on the prevention and control of pneumonia. He has spent 20 years at the rural centre of AIIMS at Ballabagrh and has a first-hand experience of primary health care issues. Relevant for today’s event is that he guided Ms.Chandra’s work on unqualified practitioners|
|Dr Soumya Swaminathan, Director General, ICMR & Union Secretary, Department of Health Research (Ministry of Health & Family Welfare)|
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