Medicine at a crossroads:“ Why today’s populist demonisation of doctors and private healthcare is counterproductive“

Medicine at a crossroads:“ Why today’s populist demonisation of doctors and private healthcare is counterproductive“

Debates over India’s current state of healthcare, both public and private, have gained momentum due to incidents that are grabbing eyeballs. With hospitals being placed under greater scrutiny there is a widespread tendency to demonise the private sector, by reducing the issue simply to the problem of “profiteering” vis-à-vis healthcare provisioning and financing.

In the absence of proper inquiry such perceptions cater to regressive tendencies and populist pressures, paving the way for public and media bashing of doctors and hospitals. There is no attempt to get the clinical perspective, details of the criticality of the case and the hospital’s opinion. However, various factors and perspectives need to be understood and addressed for an all-inclusive solution.

In terms of affordability, regulations and price controls on treatments and drugs need to take into account their economic viability based on in-depth analysis of operational cost structures. This will provide greater transparency and fairer bases of comparison.

Private hospitals use modern and constantly updated medical infrastructure with advanced technology that needs upgrades. While their revenues might have increased, importantly, overall profitability margins are rather low. There needs to be a fine balance between world class healthcare and affordability. What patients should understand is that provision of high-standard ICU care in India is rather expensive if all international norms are adhered to, but still is markedly lower than that in developed countries, for example the US.

Illustration: Ajit Ninan

Indian private healthcare is sought after for providing world class quality care at affordable costs. Worldwide, healthcare costs in India are still among the lowest, as is reflected in rising medical tourism.

Unfortunately, out-of-pocket expenditures are high in case of public healthcare also, due to multiple operational and regulatory gaps. If government hospitals comply with quality standards and international norms, sustained cost pressures are bound to limit their affordability as well. Fortunately, much of cost in apex hospitals such as AIIMS – close to Rs 1,300 crore per year – is borne by government and not patients, while private hospitals need to sustain all by themselves.

Further, public hospitals remain largely ill-equipped in terms of facilities and medical professionals are few in number and overworked. Service delivery is hampered by absence of access, monitoring, standardisation, communication channels, information symmetry and one physician-one patient ownership. Thus, despite high costs, there is a significant preference for private healthcare across rural and urban India, as reflected in multiple household surveys such as NSS.

While a certain amount of regulation is welcome, our policymakers and regulatory authorities must not be in a hurry ‘to show private healthcare its place’ in kneejerk mode. Such reactions often cater to ‘popular’ public opinions and are more because of authorities being ‘under pressure to do something in a short time’. Also, adequate investigation and indictment procedures must be followed based on democratic processes, especially regarding hospital shutdowns and lease cancellations for various inefficiencies and malpractices.

Otherwise, the fear of persecution might lead to counterproductive results, leading to hindered provision of care and delays in treatment. Physicians fearing backlash will practice ‘defensive medicine’ and hence order more tests, including expensive ones, for more ‘complete’ diagnosis.

So, instead of limiting expenditure, greater financial burden to patients will accrue. In the worst case scenario physicians may refuse to see even moderately sick patients – for example dengue patients even if they are clinically stable – referring them instead to public hospitals; thus delaying treatment and overloading already stretched public health facilities.

At a time when we need more qualified doctors and medical personnel, the medical profession is facing increasing attrition. Unlike in the US and UK India’s brightest brains, including children of physicians, are less inclined to enter the profession now given the present populist backlash against doctors. Many competent critical care specialists and surgeons are thinking of retiring or changing professions due to continued unnecessary criticism from patient’s relatives.

Such trends will result in future Indian physicians of less competence and hence more medical mistakes. Furthermore, introduction of advanced technology and innovations or planned investments and expansions by corporate hospitals will be stalled.

Importantly, the under-served and under-consumed public sector hospital must be improved, especially cardiology and intensive care units. Rather than taking decisions unilaterally, the government must initiate dialogue around issues of transparency and affordability with a consortium of all stakeholders. This will ensure policy consensus at multiple levels for health related regulation.

Moreover, regulators must ensure clarity around the information provided to patients and grey areas of decision making such as end-of-life decisions, patients leaving against medical advice, quality and use of generic medicines (about one-third are substandard, may lead to more deaths). This also extends to regulation of the information asymmetry between public and private healthcare providers and patients that allows for monopolistic powers, price distortion, over-charging, etc.

According to the Indian Healthcare Market Research Report 2016, our healthcare sector is one of the largest in terms of employment and revenue generation. Growing at a CAGR of 16.5%, it will possibly be worth $280 billion by 2020. The 2017 National Health Policy seeks to increase government spending from the abysmally low 1.4% to 2.5% of India’s GDP.

The private sector’s massive infrastructure and capability for talent generation must be leveraged through capital flows, investments, collaborations and public private partnerships across the entire value chain, to deliver on India’s need for quality healthcare and improved health