Defining Health & Population

Heed the patient

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National Medical Commission Bill must address the needs of the consumer rather than the interests of medical practitioners and quacks.
indian expressWritten by Shailaja Chandra | Updated: January 5, 2018 8:28 am

The nexus between the unqualified practitioners or RMPs (Rural not-Registered medical practitioner) is apparent from the virtual absence of action against thousands of quacks. (Illustration: Subrata Dhar)

The National Medical Commission Bill 2017, well-intentioned and forward-looking, has unfortunately stirred a hornet’s nest. It has brought to the fore a disturbing aspect of an ongoing controversy — the activities of medical lobbies that have persistently thwarted efforts to put consumer interest above their own. Parliament needs to face some unsavoury facts.

Two lobbies are at work backing the professional interests of the allopathic community on the one hand and AYUSH practitioners (mainly ayurveda, unani and homoeopathy physicians) on the other. There are some 10.4 lakh private medical establishments with hospitals accounting for under 8 per cent of them. Most are lone practitioners running small nursing homes and clinics. Most do not possess a medical qualification. A 2016 WHO study has brought out that only 58 per cent of urban doctors had a medical degree and only 19 per cent in rural areas. Only 31.4 per cent of allopathic doctors were educated to the secondary school level and 57.3 per cent did not have any medical qualification. NSSO reports show how barring the metros and large cities, there are more unqualified practitioners than regular doctors.

The interests of all allopathic doctors, regardless of their competence, are looked after by the Indian Medical Association (IMA), a voluntary registered society with state chapters which register doctors as members and lobby with the government, resorting to agitations and strikes whenever doctors’ interests are affected. An all-India membership of over two lakh gives the IMA immense clout so that most chief ministers and even the Union health ministry avoid confrontation.

Many of the IMA’s members are single practitioners and they run their clinics with the assistance of young school dropouts engaged as helpers. They train them to handle acute illnesses and treat acute medical conditions with antibiotics, IV fluids and steroid injections. Once sufficiently skilled, these assistants set up independent practice using the prefix “doctor”. They run a lucrative business charging a fraction of a qualified doctor’s fees. When patients do not respond to treatment, they refer them to a known qualified medical practitioner who remunerates them with a 30 per cent commission.

The IMA and the Medical Council of India, both at the apex level and in their state units, are aware of what is happening. While their public position is that quackery must be stopped, covertly, both organisations look the other way. The nexus between the unqualified practitioners or RMPs (Rural not-Registered medical practitioner) is apparent from the virtual absence of action against thousands of quacks. The IMA, instead, targets ayurveda, unani and homoeopathy practitioners who hive off their business. Since RMPs are part of the business and generate referrals, action — when taken — is perfunctory.

The National Medical Commission Bill 2017 and for that matter the National Health Policy 2016 overlook this countrywide phenomenon altogether. Under law, the Medical Council of India and the state medical councils are enjoined to take action against those who practise allopathic medicine without being enrolled on the allopathic medical register. As consumer safety is at stake, this is a serious omission from a bill which seeks to replace the medical council.

The practitioners of Indian medicine also constitute another powerful lobby. The National Integrated Medical Association (NIMA) lobbies forcefully in favour of “ integrated practice”. At two national events, the prime minister publicly stated that ayurveda practitioners practise modern medicine and very few use traditional medicine. Even his observation does not seem to have had the required impact.

While the propagation of traditional medicine is publicly pursued with passion, the preponderance of treating with modern medicine is ignored. Authentic ayurveda is now confined to Kerala and western Maharashtra, other than a few government-run universities and colleges in different states. In North India, it is difficult to find even 10 practitioners of pure ayurveda excluding doctors employed by government establishments and colleges.

The development and propagation of the ayurveda system is left to a handful of committed researchers and faculty members in institutions like the Banaras Hindu University, Gujarat Ayurvedic University and Arya Vaidya Sala at Kottakkal and Amrita Vishwa Vidyapeetham in Kerala. The faculty in these institutions is worried. “If AYUSH graduates are allowed to practise allopathy, where does the status and the future of ayurveda stand? They should not be allowed to practise allopathy as otherwise the AYUSH systems will die,” lamented all faculty members I spoke to.

The new Bill must take stock of and address what the country actually needs. The first need is for thousands of community-level accredited practitioners — not full-fledged doctors — who after training should be equipped to provide the first line of care for acute conditions and to make referrals to a regular doctor within a GPS-supervised system. The realisation that neither allopathic nor AYUSH doctors will ever go to lakhs of villages — not even tehsils — must dawn on policymakers. That is precisely why a new system of community-based trained health workers (not government employees) who are enrolled on the state medical register is needed. This can only be done if the medical education law provides for it.

Second, the new Bill should promote integrative medicine enabling people to access multiple choices but available under one roof, particularly for chronic conditions or even as adjuvant therapy. The developed world has recognised that with an increase in life expectancy, chronic diseases, allergic syndromes and rare medical conditions cannot be cured — but the symptoms can be mitigated through traditional medicine. A quest for bridge courses to learn ayurveda has already begun in different countries. The new Bill should recognise the scope for integrative medicine but without mixing medical systems and practitioners.

Citizens are agitated over the mismanagement of both publicly-run and private medical education establishments. The government has done well to bring forward new legislation to replace the medical council. But unless the Bill confronts reality and addresses it, keeping consumer interest paramount, the new law will make little difference to people’s lives. The parliamentary standing committee has an opportunity to make a difference, if it shuns the rhetoric of self-interest professional groups and confronts reality.

The writer is former secretary, Department of AYUSH, government of India, and former chief secretary, government of Delhi.

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A potential antidote

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Shailaja Chandra
Published on January 3, 2018

 

The Medical Bill is not as bad as IMA says it is

News that the Medical Commission Bill is to go before the Parliamentary Standing Committee has come as a relief. In its present form, the draft contains disturbing features. While it addresses many of the ills the 2016 Parliamentary committee had exposed, concerning decades-long mismanagement by the Medical Council of India, the new Act must overcome, not add to, the blunders.

To be fair, the Bill has taken care of three critically important drawbacks of the existing MCI Act. First it seeks to remove the stranglehold of doctors who for over 60 years have been deciding everything that affects their own professional well-being with absolutely no input from the very interests they profess to work for — the public. The 62-year-old MCI Act had given license to doctors to elect and appoint themselves to decision making positions — a situation which gave winnability precedence over professional competence and the need to confront serious public health challenges which go beyond clinical specialities.

By drastically reducing the elected element from the proposed Commission, the de-politicisation of the highest statutory standard setting body, greater transparency and responsiveness to the health needs of the country — not just of doctors — can be achieved.

Mandating an exit-exam is another progressive step in the Bill. It is of critical importance to test the proficiency of all graduating doctors through a common examination instead of relegating it to examining bodies with undulant standards. It would help reduce — might even end — the present mess created by partisan inspection systems, political interference and protracted litigation.

Yet, another plus in the new Bill is placing non-medical people on the Commission — a practice that prevails in many countries to safeguard public interest. It is essential to induct informed non-clinicians to bring balance and breadth of vision to decision making.

IMA’s vociferous rejection of all these positive strategies through mass representations by 3 lakh practitioners is nothing but an effort to sabotage the Bill; it shows how deeply embedded is the self-preservation instinct despite all the ills that exist. Comparisons with lawyers and engineers are mere red herrings; neither the curriculum nor the approval of colleges of those two professions are administered by their elected members.

The Bill has, however, got into muddy waters by alluding to the possibility of a bridge course in case a joint body of the medical regulatory councils decides to utilise AYUSH doctors to augment medical services. The mere inclusion of an intent has rung alarm bells. At two national events the Prime Minister himself has talked about the propensity of AYUSH doctors to practice modern medicine instead of using time honoured traditional medicine systems in which they have been trained. Any move to legitimise modern medicine practice by all Vaidyas, Hakims and Homeopaths would devalue the systems and demoralise genuine traditional medicine practitioners.

To even keep a window open to legitimise the practice of modern medicine by AYUSH practitioners negates the prescient goodness of the traditional medicine systems. From a public standpoint what India needs is a core curriculum for all students of recognised systems of medicine, to overcome the present ignorance and caste based divide that exists between different systems.

The writer is a former Secretary at the health ministry

Difficulty Climbing Stairs?

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A Lift? A Wall Hugging Chair? A Wheelchair that can Climb Stairs?

Options, Costs, Pros And Cons.

As one crosses the age of 70 ( and we’re both on either side of 75,) the question of managing stairs crops up regularly.The conversation also surfaces each time someone suffers from arthritis, backache or has a fracture.You ask yourself:

“ Should you just wait for that day when one of you needs support to go up and down stairs? How do you propose to manage that?”

The prospect of developing a heart condition, experiencing a sudden fracture or being unable to climb stairs for whatever reason is an unhappy one.Suppose one is stuck on the first, second or third floor without any back-up? Can this become a default situation for you or your husband,wife, mother or father?”

The children come on their annual visits and bring more “what if” questions.

“ Have you thought of one of those chairs that goes up and down along the wall?“ Have you considered a lift?”

I decided to undertake a literature survey and follow up with some field foot work.I am sharing whatever I have learnt.

Assuming neighbours and family are fully cooperative- (often they’re not,) here are your options:

Regular Lift option

1. Buying and installing a regular lift is terribly problematic once a house is built and lived in. It would entail first selecting and buying the lift.( The smallest Schneider variety for 4 passengers would be more than Rs 9 lakhs.) Depending on its capacity and type it would need space for a pit ( think of hammering away the floor inside or outside the house) a machine room, a place for the ropes and traction to be provided – not to speak of the drilling, hammering, breaking doors, windows, walls and roof which will be decided by the sort of house you live in. The company will demand that you get the preliminary civil works done and that will be costly .

Advice: On account of the high cost the conventional lift is clearly a No- No.The only way it would work is if there is enough space and FAR and some others in the building agree to share the cost.

Pneumatic Lift option.

2. The trigger to find out more about this sort of lift was running into a former colleague living in a DDA duplex flat in Vasant Kunj. We met each other after years and her first question to me was, ” Remember you talked about a lift some years ago? Well we did tons of research and installed one three years ago. It’s marvelous! I call it my rocket. It is a pneumatic lift which goes up-and-down from the first floor down to the ground floor right inside the house.My husband and I never need to use the stairs anymore because it’s right inside the house and occupies just one square meter of space.”

I knew her husband had a heart condition but the thought of going up and down in a lift inside the flat sounded a little bizarre. But then on WhatsApp she sent me three videos of this “rocket lift” in motion and I must say I was impressed. I requested for a contact number of the supplier. It took just one call to a Company named Grand Prix to have a knowledgeable agent calling at short notice.Armed with two glossy catalogues containing beautiful pictures of high end glass lifts for indoor use, he inspected the options in our house.

The first huge deterrent was the stated cost.My friend had paid Rs 12 lakhs 3 years ago.Now it would cost Rs 18 lakhs with GST and would be imported from Italy or Dubai.The lead time would be 4 months. I would also need to hive off 1 square meter from the ground floor and have a diamond cutting drill excavate two circles of cement – concrete in the roofs on the first and terrace floors to make a passage for the pneumatic lift.

The thought of explaining all this to my brother who is in Bengaluru over the phone and getting him to agree to drilling a hole in his Ground floor portion of the house, besides persuading him to let me annex one square meter of space ( howsoever unused, )was something I knew was destined o fail. In any case I did not have Rs 18 lakhs to spend on such a futuristic project, saddled with so many imponderables.

Advice: Drop the idea of a pneumatic lift unless you have complete independence to decide on its installation.But even so, at that price I would not advise it.At half the price it’s worth it!

Hydraulic lift option

3. I happened to meet someone who said “ Just install a hydraulic lift outside the house.It would be far, far cheaper, quicker and less disruptive.”

Encouraged thus, I rang “Just Dial At 22222222” (repeatedly advertised by Amitabh Bachan) and instantly got a list of suppliers. Even before I could start making my first call, two suppliers contacted me ( the telemarketers pass on your number to everyone in the field BTW,) and 2 suppliers set up time to come to the house to give a feasibility and cost estimate – on the spot.Both callers came on time, inspected the area and said much the same thing about the cost, time and installation requirements.

I contacted our architect – a conservative septuagenarian who had helped build the ground floor of my mother’s house in 1972. The firm was no longer building houses and had moved to industrial architecture.Even so his team was horrified at the idea of a hydraulic lift . But I persuaded them to at least meet one of the suppliers if not both.

Among the two suppliers one appeared more serious about sticking to timelines. He was a burly Sardar wearing a white safa. Although he had told me he had no technical qualifications, he proceeded to answer every question with complete confidence. When there were no more questions to be asked, the conversation got down to the business of asking for specifications and then the final price.It was quite reasonable- Rs 3 lakhs for 2 floors- ground to first to terrace. Converting two windows into outlet doors for the lift would be my responsibility but Sardarji undertook to provide a platforms between the lift and the door for access.

It all sounded doable but in my mind many questions still remained unanswered. How long would it take to be erected?

Suppose the Sardarji let me down midway? Suppose the whole business of breaking and converting two large windows into even bigger doors and erecting a platform above the sunshades to act as 15 and 30 feet high pathways into the lift looked or worse felt shoddy and unsafe?

After all you don’t live in a nice house to have some makeshift warehouse lift mucking up a clean and neat facade permanently! Besides I wasn’t sure that the MCD would take kindly to the contraption as it wouldn’t fit into their bylaws.

These forebodings apart, the price was so attractive and Sardarji’s enthusiasm so sincere that I too was convinced. A lift for three lakhs going all the way up to the terrace ! Imagine taking all my potted plants up in winter and down to the shaded portions in summer ! Imagine basking in the sunshine on the roof one minute and driving off to the market the next!The possibilities were enormous and very attractive.

It then struck me why not go and see a couple of lifts in actual use before clinching the deal?So I set up time to visit two homes in Rajouri garden and Jail Road after talking to the owners.Both had installed the lift for a mother and a wife both of whom were wheelchair bound needed to visit the hospital every now and then.They both expressed satisfaction. Armed with these telephonic assurances I met the Sardarji supplier at the Mayapuri metro station and was piloted by a him – he on a two wheeler and me in a car. I don’t think I would’ve found the addresses in 1000 years had Sardarji not zoomed ahead through umpteen turns and twists within rows and rows of houses.

The first house had rather a natty looking lift which was being used to transport the owner’s disabled wife from the first floor to the ground floor. The actual cabin and the pipe and trusses couldn’t be seen and the effect was of a smart but slow moving old Mumbai type lift.It was kept on a slow setting because the motor made a noise at high speed.

The second house I visited had made minimal investment and I could see the actual lift shorn of its smart interiors and cladding.It was like an open cage – sturdy without a doubt- but really quite ugly! Noisy too when the lift went up.Not noisy as it came down however.It was however safe and did its job.
I needed to sit down and work out all the details about the construction noise, cost, completion period , civil works, beautification and factor in all the appurtenances before taking a decision if I was going to pay a 30 % advance.

Sardarji had no place to offer except his own “office” which was in the heart of the industrial area. I followed him through the worst kind of metallic chaos coupled with deafening sounds of clanging metal, trucks dumping wares and dust and lethal fumes everywhere.We entered the factory- a large enclosure where it was impossible to make out what was gong on behind mountains of cylinders, poles lying alongside massive craters of iron scrap. Sardarji simply toodled up a rickety iron ladder which had 6 inch slats which perhaps qualified it as a “staircase”.He beckoned me to follow him with nothing to hold on to except the step above.I grasped each step above my head and climbed the 10 rungs up to his “office”. It was more akin to a metal machaan supported by a couple of angle irons. Sardarji’s spry father sprinted up and joined the discussion.Never having seen my house he too had a deft and convincing reply to every point I raised.I returned home all set to start on this project no matter what it took.But then it struck me that at least I should have a word with the tenants downstairs as the din the lift installation would entail could be insufferable.

Luckily we ran into each other late that night as I took our dachshund for her last pee under the lamppost. The couple had just returned after a late dinner and listened to me patiently.I told them my plans and requested them to put up with a lot of noise for a few days.They were unperturbed. They had no objection- except to enquire why I needed a lift in the first place!

“What is wrong with you? Why can’t you climb a few stairs?”Coming from complete outsiders it was a bit of a revelation- was I becoming unnecessarily paranoid with no plausible reason except to have a back up for a future emergency of unknown origin and uncertain timing?Had I overlooked some other option which would be less invasive and disruptive?I put the hydraulic lift idea on pause.

Electric Chair options

4. The next step was to look at the possibility of installing a chair like what dentists and doctors provide in their basement surgeries.This time I asked Google and sure enough found a company called Vin Grace and rang them up! A woman named Suchitaa answered. She sounded helpful and efficient and her answers were concise but knowledgeable.She gave the time and cost figures including for delivery and installation with the confidence that comes from having dealt with scores of customers.She came the next morning accompanied by a small wheelchair and an attendant. Wearing a smart winter coat and boots, she slipped into the wheelchair in a trice and was wheeled downstairs step by step and pulled back upstairs but facing downwards. At every step the attendant would let go and the wheelchair remained glued to the spot until a command was given by the attendant which decided what the wheelchair had to do- move ahead or stay put.It would cost Rs 3 lakhs plus GST of 5 %.

Having demonstrated the feat that this wheelchair could perform the well heeled lady went on to suggest that the wall clinging ( dentists’/ doctors’ chair) would suit our needs better as the wheelchair could not be self propelled.It would cost Rs 1 lakhs for each flight up and a separate chair would be needed from each landing up to the next.But having demonstrated everything and taken me through some impressive catalogues even Suchetaa proceeded to ask, “Why do you need anything right now? Why do you want to spend that kind of money when there is no apparent urgency?I can supply and install whatever you need in 24 hours flat. Right now I strongly advise you to use your legs!”

Advice: If someone is immobile the wall climbing chair is just the ticket.It’s not disruptive and installation takes a few hours.

Summary of Findings

  1. The regular lift idea is strictly avoidable if you are installing it in a built up house.It is just too costly and will need permissions, approvals and a license-all huge deterrents.
  2. A pneumatic lift is unaffordable and the 4 -5 month wait for it to be customized and installed negates the undoubtedly attractive idea of something sleek and user friendly.
  3. The hydraulic lift will work but you have to have immense time, energy and motivation ( plus money ) to get a really finished job.If breaking doors and windows is involved you might lose a lot of sleep and neighbors goodwill besides you might end up with an ugly eye sore which could disturb the aesthetics of the house howsoever much you beautify the exterior and interiors.That’s not part of the supplier’s responsibility so remember it’ll be your additional cost.
  4. A wall hugging chair is doable, affordable ( if you really need it )and can be ordered in a matter of a few days ( if not 24 hours as promised by Suchetaa of Vin Grace.This chair can carry one person up and down each flight.It’s safe, will work for sure and is the answer for someone who is unable to climb stairs but not an invalid ( as sitting down, getting up unassisted is required.
  5. The stair climbing wheelchair is an option if either the staircase itself or other inmates of the building restrict your erecting rails along the wall or the bannister. But this stair climbing wheelchair is also costly at Rs 3 lakhs plus; what’s more,it needs a trained attendant to give the command to move step by step. Although the battery lasts for years and the average maid can learn to operate it, it requires breaking her in to give her confidence.That depends on individual willingness to learn.

End note:

Please God let you and me not need any of these alternatives!But it’s good to know there are so many options which are available should the need arise!

Indian healthcare’s inconvenient truth

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               Shailaja Chandra

Published on November 30, 2017

 

Thanks to lax rules and lazy regulators, unqualified ‘doctors’ are taking vulnerable, ignorant patients for a ride

Unqualified medical practice is big business in India. I had a unique opportunity to research the phenomenon through a field study. The major beneficiaries, apart from those that rely on the services of unqualified health providers (UMPs), were, quite unexpectedly, qualified doctors.

The revolving door opens when a qualified doctor employs a medically unqualified worker as an apprentice. Over 18 months to five years the assistant learns the tricks of the trade — prescribing drugs for practically all outpatient conditions — vomiting, diarrhoea, fever, crashes, joint pains, respiratory distress, abdominal pain, flu, typhoid, dengue besides children’s illnesses. The door closes when the UMP sets up his own practice but re-opens when the UMP starts referring his patients to the doctor for earning commissions.

Jhola chaaps

Across every district in the country and in every village, slum and the unorganised areas in all cities these quacks known as RMP’s, jhola chaap doctors, Bangali doctors or just quacks, thrive. WHO (2016) reports that as many as 57 per cent allopathic doctors in India do not have a medical qualification. Even when free facilities are available in the vicinity as is the case with urban slums and nearby public sector dispensaries, the poor go to quacks as the first port of call.

For the daily wage earner the incapacity to report for work means a loss of wages which must be circumvented at any cost. He has no capacity or willingness to ponder on obscure things like side effects or drug resistance. For him the nearby UMP’s treatment is a one stop transaction, cheap and available 24×7. There is security and comfort in knowing that the neighbouring community also relies on the UMP whose treatment generally works.

Besides, attempting to go to a Primary Health Centre (PHC) where the nearest Government doctor is located is beset with problems. According to Census data most PHCs are located five, 10 or more kilometres away from the surrounding villages.

Getting there would necessitate taking the patient on a cycle, a two wheeler or by bus only to find that the doctor is absent or medicine unavailable. The second alternative is to go to a private practitioner and pay a minimum of ₹200 over and above outgoings on transport and incidentals.

Considering the generally “effective” and inexpensive treatment that a village or slum based UMP provides going to him in the first instance is a no-brainer. And given the time, cost and convenience factors this trend is unlikely to change.

A marriage of convenience

How did the UMPs acquire skills to treat medical conditions? They learnt what they know from qualified doctors who engaged them as helpers. Once they leave the relationship grows into a marriage of convenience when the UMP provides a regular supply of patients and receives commissions (up to 30 per cent of the fees charged) for this service.

Women UMPs too are in high demand. Trained under qualified doctors who hired them as cheap help during deliveries, these skilled birthing attendants eventually move on and open their own maternity businesses. The ones I met were smartly turned out and articulate.

They describe every detail of how labour is induced; including the use of oxytocin injections after the dilation is sufficiently advanced. They could recognise pregnancy complications and were astute enough to refer cases to qualified doctors in time. The cost of delivering a baby here remains less than one quarter of going to a doctor’s clinic.

Pseudo pharmacists form another large and ubiquitous category. They readily sell antibiotics and steroids over the counter based on stated symptoms and by recalling AIIMS and other senior doctors’ prescriptions for given conditions. In addition the medical representatives of pharmaceutical companies were their trusted allies as they gifted them a bagful of free samples on every visit along with a tutorial on medical conditions and drug dosage.

Often such dawai (medicine) shops were owned by doctors but the front face was a qualified pharmacist who was but a proxy.

A fourth category of UMPs were found dabbling in a mixture of allopathy, Ayurveda, homoeopathy — even electro-homoeopathy. From signboards and the display of a wide variety of medicine it was apparent that they were in demand for treating gupt rog (secret diseases) aka sexually transmitted diseases, reproductive tract infections, sexual problems and piles.

Taken together the number of such practitioners is enormous. Few have anything more than a school education and even those who are graduates have not studied medicine. Their framed certificates and diplomas generally hark back to medical sounding titles which are all unrecognised.

In a 2015 working paper by Shailender Kumar Hooda an economist working with the Indian School of Industrial Development he has decoded NSSO data to show that there are 10.7 lakh medical establishments in the country.

Of these only 8 per cent are hospitals and the overwhelming majority are single practitioner enterprises run by unqualified practitioners.

Missing in action

One might well ask what different regulatory agencies are doing, knowing full well that this phenomena is entrenched in the lives of the poor. Apart from the side effects of using steroids and antibiotics irrationally, the greater risk is the probability of spreading multi-drug resistance in the wider population.

Under law the Medical Council of India and its state chapters are responsible for taking action against those who practice medicine without a medical qualification. Responses given by the Health Ministry to Parliament have invariably stated that it is for the State Medical Councils to take action. The Indian Medical Association castigates quackery but does not deregister its members from training and then paying commissions to UMPs to garner patients.

Other law enforcers too have safe alibis. Police officers and district magistrates even when they see what is tantamount to cheating and impersonation do nothing because the offences are not “cognizable”.

In other words arrests cannot be made without a complaint — something no member of the public is willing to give. The State Drug Controllers have a responsibility to ensure that prescription drugs (of which there are nearly six hundred listed in the Regulations,) are only sold under a doctor’s written advice. In fact there is virtually no checking.

While most State health departments prefer to look away, West Bengal began training the RMPs some seven years ago with the stated aim of preventing harm. Regular training classes have been organised using funds provided under the National Rural Health Mission.

It is another matter that unsupervised use of antibiotics, steroids and fourth generation drugs has serious costs for society and ought to give nightmares to all authorities. To ignore an inconvenient truth any longer would be iniquitous, unprincipled and dangerous.

The writer is former secretary, Department of AYUSH

Interview: ‘We need a medical regulator that is more like a tribunal and not the consumer court’

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Shailaja Chandra, former secretary in the health ministry, says existing laws have failed to regulate India’s healthcare sector.

Two recent events have put the private health sector in India under intense scrutiny in recent weeks. One is the death of seven-year-old Adya Singh at Fortis Memorial Research Institute in Gurugram. The child had been admitted in the hospital with dengue and died there after 15 days. Her family said that they had been billed Rs 15 lakh, an amount that most believed was grossly inflated. A government investigation into the case found irregularities, unethical practices and violation of the protocol for diagnosis and medical duties. A doctor at the hospital has been charged with culpable homicide and local authorities are considering action against the hospital management.

The second case is that of Max Super Speciality Hospital, where a premature infant, declared dead and handed over to the parents, was later found to be alive. Although the child was taken back to hospital for treatment, he did not survive.

These two cases are only the latest in a long list of reported malpractices, negligence, and ethical violations at private hospitals across India. The main reason that these violations are all too common is the lack of strict and uniform regulation of healthcare in the country.

In a conversation with Scroll.in, Shailaja Chandra, former secretary in the health ministry, highlights how the private medical healthcare system of India is set up in such a way that there is little accountability, how there are numerous gaps between old laws that are irrelevant to new healthcare systems and new laws that are robust but not being implemented, and why there should be a body to oversee healthcare just like there are for telecom and aviation.

Excerpts from the conversation:

In any country or system of healthcare you will have cases of medical negligence because no system is perfect. And human error is possible because so many people – doctors, nurses and different levels of staff are involved in patient care. But medical negligence seems to be happening with alarming regularity in India…

The private health sector is the outcome of a policy climate that encouraged the establishment of specialty hospitals. During the 1980s up to the time of liberalisation, there was nothing like a private healthcare sector other than small nursing homes, which took care of maternity cases and so on. For complicated cases patients were taken to public sector hospitals like Safdarjung or Lok Nayak Jayaprakash Narayan or Ram Manohar Lohia or the All India Institute of Medical Sciences. There was nothing like corporate hospitals. Then, between 1992 to about 1998, a slew of concessions were given and Foreign Direct Investment was permitted for the health sector. With that, foreign money and Indian money could come into the health sector, treating is as an industry. Land was given at concessional rates to hospitals as well as income tax exemptions and huge customs duty exemptions. This ensured that it was worthwhile and profitable for investors to invest in the health sector.

Between 1991 and 2000 when I was in the health ministry, I do not remember any parliamentary briefing or any meeting with the secretary or my colleagues when this subject of regulation of private health sector was even mentioned. We were all wrapped up in projects on malaria, leprosy, TB, blindness, food adulteration and all those things. Not once did the subject of regulating the private health sector came up.

Regulation was only confined to asking hospitals to earmark and admit patients from the weaker sections as per the undertaking given while availing of the concessions, generally providing 10% of in-patient department and 25% outpatient department care free of cost. Even this was completely unsuccessful. The health ministry had no power or political will to enforce it.


This lack of regulation has continued over the years even as more private health establishments have been set up, which is particularly troubling in a country where there is low penetration of medical insurance and more than 60% of healthcare expenditure comes out of the patients’ pockets.

Super-speciality corporate hospitals hire highly qualified people, have state of the art equipment and are highly organised. So a man who has money but no insurance, has at least this outlet where he might be paying four times what he should but he gets the service.

Meanwhile, the health sector in small towns offering medical or surgical services is dominated by single practitioners only. Of the 10.4 lakh healthcare enterprises, which include hospitals, nursing homes, diagnostic centres and laboratories about 8% are hospitals, while 50% are single practitioners. Of the 50%, unqualified practitioners account for more than the qualified doctors. This creates a bottleneck where only people with resources can go to specialty private hospitals while the rest have to go to small nursing homes or depend on overcrowded government hospitals.

Once admitted into a high-end private hospital, patient has no estimate of what the ultimate bill might be as the hospital charges whatever it wishes to. Private hospitals are in it for profits and do not operate based on charitable or altruistic motivation. Therefore, these horror stories of people being overbilled are often correct. If you look at private hospitals, there will be anything from a 100 to 500 cases against each in consumer courts, most often about billing.

In many private hospitals, the doctors or management do sit down with patients or their families and have a kind of counselling telling them what their bills are running into, so that there is no shock at the end. But not everyone does it. The worst-case scenario is of reports of a patient being forced to be on ventilator when it was unnecessary after a couple of days or when the patient was already brain dead. But they would have billed him for 10 days when he would have needed to be in the ICU for only two days. But this is the version of patients.We need an unbiased body which can look at the facts and decide and in the absence of that it is a family’s word against a hospital.

Shailaja Chandra, former secretary in the health ministry.

Where have the various existing medical regulations failed?

Every state has a Nursing Homes Act, drawn up around the 1950s, which not at all attuned to the kind of healthcare institutions in the country now. The Acts require all establishments to be registered and their licences can be cancelled, but there are no provisions on malpractice or overbilling and so on.

The Medical Council of India is supposed to set standards but it only registers doctors on the medical register of India. State medical councils enrol doctors on state medical registers. Now, medical councils are elected bodies and members have to fight elections. Their purpose is to look after the interests of doctors and not to annoy them with enquiries and punishments – very rarely does the council resort to suspending a licence of a doctor, leave alone cancelling it. There is virtually no oversight of doctors or deficient or unethical treatment by the national or state medical councils.

The Clinical Establishments Act 2010 covers every kind of medical establishment, whether it is a laboratory, a single practitioner or corporate multispeciality hospital, public sector or private sector. It was passed by parliament in 2012 but has not been implemented properly by any of the states. That requires rules and staff to undertake the functions and act if the information given while registering an establishment is disregarded or circumvented.

What has been the biggest hurdle to implementing any kind of regulation?

There is huge resistance by doctors mostly at the state level, especially by the Indian Medical Associations who have stone-walled any efforts to regulate. Being so it is a controversial subject that the political executive at the state level would rather not confront. Only Karnataka and West Bengal have tried to bell the cat, by passing state-level laws, where they have faced a lot of resistance.

Other state governments see it as more of a political thing because they have now realised that for the first time in India there is a public uprising about issues connected with the quality and pricing of healthcare. People may not be articulating it as such but they are mad about inflated bills, wrong diagnosis, over treatment, under treatment and all other kinds of things, including how a patient is not consulted or counselled about anything in a hospital.

How do we now start making health establishments accountable?

Apart from implementing the Clinical Establishments Act which is a must, we need a regulator that is more like a tribunal and not the consumer court. The consumer court only looks at faulty service and award of compensation and has no medical advice available to it while deciding case of medical negligence or malpractice. A particular administrative member may or may not have a health background. Even among lawyers, there are only those who add on to their areas expertise and do a little of medical negligence and malpractice cases but there are no specialists in these areas. Medical negligence and malpractice cases need lawyers that can interpret medical findings and are conversant with best practices and treatment regimen. So, you can’t sue a doctor for anything and you are only stuck with the consumer court. The consumer court has a long pendency and might be looking at a case of the operation of a toaster or lift and case of a hospital on the same day. That is not the ideal forum.

We need medical tribunals starting with an ombudsman at the sub-district level, a district forum, a state forum and a national forum. Each of these should have a judge, a doctor and a medical administrator who knows about hospital administration. We need such medical tribunals that can look into these specific cases of malpractice, negligence, apathy and overbilling.

For that, we need standards. If you look at any district in India, there will be a qualified doctor but he needs help with his practice. So, he picks a guy literally off the road and teaches him how to put intravenous fluids and such medical procedures. These assistants watch how doctors prescribe antibiotics and steroids and learn the repertoire of about 20 medications and how to give them for day-to-day problems. These unqualified then assistants start treating patients on their own and refer the cases that they cannot handle to the very doctors who trained them for a commission of around 30%. This is very common and the Indian Medical Association does not deny this.

So, you have a situation where at the lowest level there are no qualifications prescribed and all your technical people, even non-doctors, could have learnt skills anywhere. Now, there is nothing wrong at one level just as you trust an electrician who has no qualifications but can set right almost anything in your house. He doesn’t know the physics of it but he knows the mechanics of it. In a poor country there will be this informal kind of business. But, should health be treated as such?

This is not just a question of regulating the lowest level but there are no standards anywhere all the way up to corporate hospitals. It is all left to market forces.

The Clinical Establishments Act has drawn up standards that hospitals must meet and needs healthcare providers to declare the services provided and their. If there are transgressions of these standards, the authorities can cancel registration. This should be implemented without further delay across the country. If the states do not listen the subject of medical standards and quality of care should be brought on the concurrent list of the Constitution.

The Delhi state government has cancelled Max Super Speciality Hospital’s licence on grounds that it has not offered free treatment for the poor as per the agreement with the state government based on which it got land at concessional rates. The hospital was also supposed to reserve beds meant for fever patients but has used it to treat other cases. And then there has been this this case of alleged negligence. But doctors have made a point that forcing the hospital to close will leave patients in the lurch. How do you think this should have been handled?

When I first heard about what had happened at the hospital, I felt that it was high time someone took action against the hospital and said so in a television interview when they asked me. But I would have to go back on that because it cannot be a situation where you close the whole hospital. The first priority should be giving patient care, not disciplining the doctor or hospital. However, I would say that if they have not been providing the free treatment that they are supposed to, then they should have been given a month’s notice saying that the hospital will be closed down and informing patients through public notice that the hospital will be closed and that they have to make other arrangements.

You cannot shut a hospital overnight, because there are a lot of critical and serious cases for which treatment cannot just be stopped. These are not just consultations but operations, dialysis, haemophilia cases where treatment is going on all the time and over a period of time. You cannot leave those patients in the lurch. Patients have to find another doctor, get an appointment and in doing this can lose precious time and may lose a life.

Before the Karnataka Private Medical Establishments Act was passed last month, one of the contentions of doctors who were protesting the Act was that public hospitals were being left out of this set of rules. Should there be separate regulations for public and private hospitals?

No, and the Clinical Establishments Act covers public and private establishments. All state regulations should cover public and private medical establishments. Public hospitals have enormous problems. For instance, government doctors siphon off patients telling them to come to their private practices where they charge them five times the cost. They also need to be put under check. There are many ways whereby the medical sector can be regulated and, indeed, that is a crying need today.

Regulate the private health sector

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NEW DELHI | FRIDAY, 29 SEPTEMBER 2017

Like telecom, power, and aviation, we need a regulatory system for health care at a all levels

SHAILAJA CHANDRA

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.

NEED FOR OMBUDSMAN: What hurts patients the most is the absence of regulation in things such as standards, quality, and cost

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

Unqualified Medical Practitioners In India – The Legal, Medical and Social Dimension of Their Practice

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HEALTH TALK “Unqualified Medical Practitioners In India – The Legal, Medical and Social Dimension of Their Practice”

at

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)