Health system regulation in India

 The medical establishment has become a threat to health

– Ivan Illich begins his book “Limits to Medicine: Medical Nemesis” (1975) with these lines

Going by recent events, Illich’s trenchant criticism of Western medical

establishments is also pertinent to healthcare in India. First, there was Aamir Khan’s Satyameva Jayate TV episode on corruption in India’s healthcare sector, which provoked anger at the system and discomfort at (what some felt was) his sanctimonious treatment of the issue. Then, the entry, exit, and re-entry of an allegedly corrupt doctor, Ketan Desai, as head of the Medical Council of India

made news.

Last month, the debate flared again when an article by an Australian doctor, David Berger, on corruption among Indian doctors appeared in the ‘Personal View’ section of the prestigious British Medical Journal. Reputed doctors and CEOs of large corporate chain hospitals challenged what Dr. Berger characterised as “kickbacks and bribes (that) oil every part of the healthcare machinery”. They defended their position on television claiming that the entire profession is being blamed because of a small minority. But is this commentary in a leading medical journal about a rare practice among a few errant doctors? Why should an article that is not even based on primary research anger doctors so much? While self-regulation in the medical profession has clearly failed, a critical assessment of our health system reveals a strong competitive market-oriented system, rather than a system that privileges people’s health and well-being.

Epidemic of corruption

Corruption in government health services often makes news, such as informal payments to healthcare providers to obtain services, skimming off the top of district budgets in the National Rural Health Mission, and kickbacks in procurement of drugs and consumables. The Karnataka Lokayukta, for example, estimated that up to 25% of health budgets gets siphoned off due to corruption in government health services. From childbirth to post-mortem examinations, bribes are paid for many services in government hospitals and, often, the poorest people are most vulnerable to these practices.

The private sector is no different. Many people, especially the poor, seek treatment from private clinics and hospitals, where doctors often take commissions or ‘cuts’ for drug prescriptions or laboratory diagnostics. The zeal with which laboratories seek the details of the referring doctor could easily be mistaken as harmless collection of information. However, the elaborate system of routing kickbacks to the referring doctor is an open secret among the medical fraternity. Large private hospitals have close associations with pharmaceutical companies, creating conflicts of interest in medication and prescriptions. Pharmaceutical companies routinely employ smartly dressed business management graduates to ‘massage’ doctors into prescribing particular brands of drugs, often providing attractive gifts and sponsorships in return. Such encounters are neither recorded nor their content regulated.

Private medical colleges have mushroomed in many states because of the lucrative business of generating much-needed medical specialists, but many operate courses of questionable quality. The Medical Council of India that is empowered to grant or revoke recognition to new medical colleges, discharges its responsibilities in an ad hoc manner. The situation that an India Today exposé documented a decade ago—detailing the malleability of these inspections, the blatant exchange of favours and gifts, and the flagrant flouting of norms, —has not changed much even today.

The lack of governance and regulation results not merely in ethical problems, but aggravates the poor health outcomes of our country in comparison to our neighbours. This is evident in the several recent health policy research studies that have shown the health effects of poor governance of public services and weak regulatory capacity of our health system.

Systemic problems

A doctor-patient relationship is built on trust. Despite being recognised as a consumer-seller relationship under law, patients lack the information needed to choose the best decision in their own interest. Unlike buying a cellphone, where buyers know what features they want, in healthcare, such decisions have to be made placing trust in the doctor’s technical knowledge and skill. But what if there is a conflict of interest between a healthcare decision that is in the interest of the patient and an incentive to the doctor, as is often the case? Will a doctor resist a few supplementary thousand rupees for referring a patient for an MRI scan? Will he refuse an all-expenses paid foreign trip or a sought-after gift for his clinic in exchange for increasing medicine prescriptions? Should we as a society allow healthcare to be delivered under such a perverse system? The doctor who overlooks the well-being of the patient to benefit financially is being unethical to his profession and his patient. While that is deplorable, what of the system that allows such decisions to rest upon the goodness of the doctor? Irrespective of what proportion of doctors indulge in unethical practice, an impartial regulatory system is needed.

The primary goal of a health system is to ensure health and well-being. Principles such as patient safety, quality of healthcare, and equity should be privileged in the governance of such systems. However, we seem to have designed our health system on the principle of competition, while patients suffer under the crippling asymmetry of information. The doctors and hospitals compete for patients, while the patients get to choose doctors and healthcare services based on the best information they have. Such market-based prescriptions have costly side effects for patients. Patients, a majority of whom are poor and can barely afford healthcare, have to ultimately bear the additional costs of these kickbacks and the decreased quality of care.

Implementing regulations

It is not for lack of regulation that we have ended up this way. The few well-conceived regulations we have, are hardly implemented. The Clinical Establishments (Registration and Regulation) Act, 2010 is supposed to enable registration of private healthcare establishments of all systems of medicine, laboratories and diagnostic centres, and single doctor establishments. Early efforts at registration and regulation have shown very poor results. For example, in Karnataka over a thousand private healthcare establishments are probably running unregistered in 2014. Furthermore, registration hardly matters; when it is not accompanied by minimum standards of practice and care, it is rendered ineffective.

Self-regulation among doctors has also failed. The ability of medical professionals to introspect collectively is low. Self-regulatory associations, such as medical and dental associations and statutory bodies like the medical councils, are looking out for their profession, as is perhaps their mandate. They are behaving like trade unions or guilds, prioritizing members’ interests over public health concerns. If the state does not step in to safeguard the citizen’s interest, who will look out for the patients? Our health system is crumbling and patchwork will not do. The state urgently needs to take up the interests of the patient, because the doctor is otherwise busy.