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.
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
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.
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.
After the government capped the education grant for the children of of soldiers killed in action, those missing or disabled, the veterans are outraged. Why dishonour us, they ask. As the government looks at reviewing its order, on The Buck Stops Here we ask – how could such oversights happen in the first place.
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Earlier this year, the Supreme Court issued guidelines to curb the alleged misused of Section 498A of the Indian Penal Code, meant to deal with cases of dowry-related abuse. While men’s rights activists claim the law is a tool for extorting husbands and their families, women’s rights activists feel the dilution of 498A will be an attack on gender justice. On this episode of We The People, we ask: Is 498A really the most abused law in the country? With no bankable data on the level of abuse of the said law, did the Supreme Court jump the gun with the July ruling? Will the top court, in its upcoming review of the law, be able to find a middle ground between the warring groups?
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Senior bureaucrat Aruna Sharma has lashed out at what she calls the “narrow approach in the name of women’s rights”. She believes this has led to a rampant misuse of law by women, asserting that such “activism” is resulting in men losing faith in the judiciary and the institution of marriage.
Is the call to revisit some of our gender laws and their implementation valid or exaggerated?
What steel secretary Aruna Sharma wrote about the misuse of Section 498-A, and protecting men from baseless complaints were her personal views. But she has highlighted a truism which is almost never discussed, but ought to be. Section 498-A is sometimes misused and rather that helping women, sexual harassment laws are being used for extortion.
In July 2017, the apex court wrote a 20-page order explaining how the provision was being misused, and set out a detailed process to be followed before any arrest could be made. Anyone interested should first read the order.
I have personally known parents of a boy charged under 498-A cowering on a bench outside the office of the Crime Against Women cell of Delhi Police.The daughter-in-law in question had a mental condition which was not revealed when the marriage was arranged. But within a few days, the new bride ripped her trousseau and her husband’s suits with a pair of scissors. Her parents slapped a case under 498-A against a decent family whom I can safely vouch for, including their son whom I had known from infancy. The hapless family became victims of extortion and had to buy their way out as nothing else (including my clout) could work.
Another real life story: a strict no-nonsense principal of a Delhi University college was hugely resented by a highly politicised faculty. Unable to bully him with threats and gheraos, they cooked up a sexual harassment charge against him, and got a pliable college complaints committee to hold him guilty.The principal still retains his job after 5 years because an independent inquiry revealed he had been framed.
On women taking advantage of female predicaments to skirt office discipline, Aruna is right. Many women officials take full advantage of their gender to parry late sitting, working over crisis-ridden weekends, and accepting traveling assignments. Most men silently curse, but are scared to confront women (or overlook their promotions) for fear of complaints.
As a woman officer who has seen it all, here’s my advice: restore a sense of balance: men and women related complaints aren’t always black and white affairs. The 2017 two-judge order is sound and sensible. Just implement it!
Shailaja Chandra is former secretary to the government of India and former chief secretary, Delhi
Unqualified Medical Practitionersin India – The Legal, Medical and Social Dimensions of their Practice
e-Report by Shailaja Chandra, Shiv Nadar University, New Delhi
Existence of Unqualified Medical Practitioners (UMP), commonly referred as quacks is known to most of Indians: It took a person like Shailaja Chandra a distinguished administrator from the Indian Administrative Services to embark on a detailed study on UMPs in India. It is so difficult to publish and distribute books in today’s digital India and hence this publication has been simply put out on the digital platform as an e-book.
The contents of the book is in fact a report by the author on an extensive analysis covering the legal, medical and social dimensions of the unrecognized and illegal healthcare delivery undertaken by the UMPs in the nation.
The report spanning over 11 chapters cover a wide ground. The magnitude of unqualified practice forms chapter 2 after an exhaustive but crisp introductory chapter on the perspectives of the area. The author perhaps for the first time has conducted a limited market survey and documents the finding of the survey in chapter 3. The origin of quacks, where from they come, how they get qualified to do what they are doing, occupation and earnings as a doctor, how they update their knowledge on diseases and medicines and the whole gamut of their operations. The sinister linkages of UMPs with qualified and registered doctors in the vicinity including the financial dealings are well captured in this chapter 4. The nexus between pharmaceutical firms and UMPs and doctors are also covered in this chapter. The contents of this chapter is really damning and would have made real “breaking news” if any media takes it up. However in the later chapters the changing scenario and a limited but positive role played by UMPs in providing healthcare and treatment to the poor and needy is captured.
The emergence of an approach to train such UMPs to limited aspects of the diagnosis and treatment thereby providing some legitimacy to their positive contribution and reducing the risk of their medical practice is discussed by the author. Any sensitive reader aware of the problems of effective healthcare delivery in a vast country like ours would be emotionally moved to read the overall apathy, non-application of policies, and a recognition of the existence of UMPs by the parliamentarians, administrators, healthcare professional groups and even the courts. The description of responses received from The Delhi Medical Council,The Indian Medical Association, Health Policy Administrators is so disappointing and clearly defines the territory protection and turf war only and not any honest attempt being made towards either completely banning and eliminating quackery and UMPs from the system or finding practical implementable solutions to combat the problem of practice by quacks.
A good analysis of the regulatory provisions applicable to UMPs are dealt in the chapter 9 on law on UMPs. One silver lining of West Bengal example where experiments are ongoing to provide limited professional training to UMPs in specific disease areas post which they are being used to provide primary support in healthcare is documented in chapter 10. The author provides possible approaches for way ahead to tackle this area, which are still solutions in the fringe but does not provide a bite the bullet solutions. The book/report does not provide existence of quackery and their impacts in other parts of the globe nor strongly recommends implementable practical solutions. Perhaps this is not part of the project and study undertaken under the Center for Public Affairs and Critical Theory – C-Pact of Shiv Nadar University.
The report is an eye opener providing exhaustive coverage of all aspects of UMPs, and it would be worthwhile to follow-up by a nationwide market research to quantify the existence and extent of UMPs across the country.
A non-conventional disruptive change initiative is needed in this area. Society will force changes even if regulations or professions do not do so as consumers perhaps will push the boundaries. A similar study on the existence and extent of unqualified paramedical professionals including pharmacists, diagnostic lab personnel is the need of today. Students of Pharmacy Practice, Presidents & Secretaries of Pharmacy Councils new emerging courses in healthcare delivery related subjects, management graduates can take leaf out of the report for their knowledge and research in healthcare practice deliveries.
Long years of administrative expertise of the author/ investigator is truly reflected in this study and so well written report.
Dr D B Anantha Narayana, Bengaluru
Guests: Dr. Puneet Misra, Professor of Community Medicine, AIIMS; Shailja Chandra, Former Health Secretary, Government of India; Dr. Shridhar Dwivedi, Senior Consultant, National Heart Institute
Anchor: Frank Rausan Pereira