Plight of doctor-owned small healthcare establishments

Health Care Comments Off

Dr KK Aggarwal and Dr Rajiv Dhir

India is the 7th-largest country by area, a pluralistic, multi-lingual and multi-ethnic society and the 2nd-most populous. With a population of more than 1.2 billion people, India is home to one-sixth of the world’s population occupying less than 3% of the world’s area.

Delivering affordable health care to India’s billion plus people presents enormous challenges and opportunities for the medical fraternity. The practice of medicine is becoming increasingly complex and time consuming. Political ideologies play a distinctive role in determining the health policies of our country. India made phenomenal economic gains in the last three decades, but has failed to improve the health status of its population on similar terms. We continue to have the distinction of having the largest number of infant deaths, maternal deaths and tuberculosis cases in the world.

Compared to the previous year, the Union budget for the year 2017-18 shows an increase of 23% in the allocation for healthcare. Since it accounts for just 1.3% of GDP, it shows the hollowness of this apparent increase as it is nowhere close to the proposed increase in the public health expenditure to 2.5% of the GDP in a time bound manner in the new National Health Policy released this year. Even this proposed increased is not enough. Health Budget should be 5% of the GDP.

India’s health sector continues to be among the countries with the lowest relative public expenditure on healthcare. Even Nepal spends a higher proportion. On the other hand, private sector facilities, largely in the specialist and super specialist segment, continue to grow and are recognized as one of the best in the world.

As high as 86% of rural population and 82% of urban population are still not covered under any insurance scheme, public or private. People in villages mainly depend on ‘household income or savings’ and ‘borrowings’ to fund hospitalization expenses. This reflects the failure of the government in expanding the reach of government health facilities and insurance cover in rural areas. According to a government survey, people in cities rely much more on their ‘income or savings’ (75%) than on ‘borrowings’ (18%) to fund their treatment. Earlier studies have repeatedly shown that India has among the most privatized healthcare systems in the world with ‘out of pocket’ expenses accounting for bulk of medical spending.

Right to health is still not a fundamental right in the Indian Constitution. Most provisions related to health are in Part-IV (Directive Principles). These are:

• Article 38 says that the state will secure a social order for the promotion of welfare of the people. Providing affordable healthcare is one of the ways to promote welfare.

• Article 39(e) calls the state to make sure that health and strength of workers, men and women, and the tender age of children are not abused.

• Article 41 imposes duty on the state to provide public assistance in cases of unemployment, old age, sickness and disablement etc.

• Article 42 makes provision to protect the health of infant and mother by maternity benefit.

• Article 47 make it the duty of the state to improve public health, securing of justice, human condition of works, extension of sickness, old age, disablement and maternity benefits and contemplated. Further, State’s duty includes prohibition of consumption of intoxicating drinking and drugs are injurious to health.

• Article 48A ensures that State shall Endeavour to protect and impose a pollution-free environment for good health.

The above description makes it clear that most provisions related to health fall under the Directive Principles of State Policy in the constitution. They are non-justifiable and no person can claim for non-fulfilling of these directives. However, Judiciary has widely interpreted the scope of Right to Health under Article 21 (right to life) and has thus established right to health as an implied fundamental right. Not only article 21 but also other articles under Part-III have been linked to Right to Health.

Further, in relation to the serious medical cases, the Supreme Court has provided certain directions such as:

• Provision of adequate health facilities at public health centers.
• Upgradation of sub-divisional level hospitals to make them capable of treating serious patients.
• To ensure availability of bed in any emergency at State level hospitals, there should be a centralized communication system so that the patient can be sent immediately to the hospital where bed is available in respect of the treatment, which is required.
• Proper arrangement of ambulances adequately provided with necessary equipment and personnel.

India has fundamental problem with focus and allocation of health resources, which are quite urban centric.

A survey by Indian Medical society had found that 75% of the qualified consultant doctors practice in urban centers, 23% in semi urban areas and only 2% in rural urban areas (where 65% of the total population live). As a result, essential expertise such as handling medical emergencies, complications of pregnancy and childbirth, treatment of acute and severe infection in children and in geriatric patients, injuries and acute surgery, are compromised in rural areas.

The real challenge which India faces is providing affordable healthcare to her citizens. The idea of healthcare as a social and welfare concern and the idea of healthcare as a business are contradictory and this can be seen very clearly within the country. The private sector in the healthcare industry, though is a better provider of quality medical help, it is also expensive and often, restricted to the urban – and by extension, the more well-off population areas. The fact that the rich-poor and the rural-urban divide is so great that majority of the people in India do not have access to quality healthcare. Private hospitals within the cities are expensive and they have no choice but to resort to the government hospitals that are not all that well equipped. The sad part of it is that, as a potential investor, any company would want to set up a healthcare centre in a place where returns are assured – rural areas are not deemed as being profitable, despite the fact that it is a place where the need and demand are the maximum.

The Government has failed miserably in proving high quality, affordable healthcare to all. As things stand today, 20% of the population is served by the public sector while the private sector caters to the rest 80% of the population.

Private health care in India is provided by the Corporate Hospitals and Nursing and Maternity Homes. In the corporate hospitals, the costs are prohibitively high while the advantages such as accessibility, affordability, and personalized service are still the USPs of Nursing and Maternity Homes, the smaller healthcare establishments.

The government believes that it is the social responsibility of the Nursing and Maternity Homes to provide affordable healthcare to all to the extent that it expects that on humanitarian grounds all emergency cases should be treated, even if the patient is not able to pay. In acid attack, one is required to treat at all levels of treatment.

While the Nursing and Maternity Homes are willing to shoulder the responsibility, a great dichotomy exists with the Government labeling Nursing and Maternity Homes as a commercial activity. While the Govt demands that medical ethics be followed and considers the health sector as a service sector, branding the private sector clinical establishments as a commercial activity contradicts Govt policy.

Also, they have been put under the purview of various laws such as the Consumer Protection Act, Medical Council of India, State Medical Council, IPC, PCPNDT Act, Surrogacy Act, ESI Act, Provident Fund Act, Labor Act, Consumer Court, Human Rights Commission and the Clinical Establishment Act (CEA).Even clinics owned by a single doctor providing only consultation services are not exempt from the Clinical Establishment Act. These doctors are already covered under the Medical Council of India Act and are regulated by the Medical Council of India or State Medical Council.

There is no single-window accountability; they can be tried simultaneously under multiple laws. Similarly, there is no single window registration for doctors and medical establishments.

In addition, the property, water and electricity are charged at commercial rates. We buy diagnostic machines in dollars and are expected to charge from patients in Rupees. A diagnostic test which costs Rs 25000 in the US using the same machine bought at the same price is being done in less than Rs 2500 in India.

Nursing and Maternity Home owners are expected to donate generously to Political Parties and Religious Organizations. Moreover, they often must hold Free Health Camps for various Social Organizations. The private sector is also expected to provide free ante-natal services (ANC) on the 9th of every month on a voluntary basis to pregnant women under the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) of the government.

People are often unaware of the hidden costs of the health-care facility and consider the doctors’ fee as the full charge at the facility, leading to a feeling that treatment costs are disproportionately high. There is also a pre-conceived notion that the private sector is always profit-driven. In the event of a mishap occurring, the people take out their ire and frustrations on the doctor or the healthcare establishment. In a bill of one lakh in the hospital, it is the hospital which takes the bulk of the total cost; the doctor’s fees may be less than 10%.

In addition, the Government wants to put a cap on the fees, which a doctor in the private sector should charge. This leads to under-cutting of prices by health-care providers to maintain patient’s loyalty, which in turn leads to compromising on certain facilities.

This is unfortunate since it is a no-win situation all round. This may be the reason why many smaller nursing homes, which can provide longer hours of service and emergency services which the patients demand, are no longer economically viable. This indeed is sad.

Dr KK Aggarwal
National President IMA & HCFI