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Health of our healthcare system

Amitabha Bhattacharya |

How pervasive is corruption in our healthcare system? Has the large-scale entry of private sector in healthcare and medical education, especially from the early 1990s, changed the scenario altogether? Is the abysmal public expenditure of about 1.3 per cent of our GDP the main reason for this sorry state of affair?

How has corruption in the main regulatory authority, the Medical Council of India (MCI), impacted the health of our healthcare sector? Is the asymmetry of information available between the patient and the doctor being exploited by the latter? Is the lack of informed public debate in the media encouraging such political apathy?

These and related questions have been discussed in two important tomes, published in about a year’s time. The first is titled “Do We Care? India’s Health System”, 2017 (DWC) authored by K. Sujatha Rao, former union health secretary; the second “Healers or Predators? Healthcare Corruption in India”, 2018 (HOP) is a compendium of investigative essays, edited by two eminent surgeons, Samiran Nundy and Sanjay Nagral, and former union health secretary, Keshav Desiraju.

Between these two works, virtually every major issue plaguing this sector has been covered. DWC provides a detailed sectoral view, as seen by a perceptive administrator who had spent over two decades in this field. HOP concentrates on the corruption aspect, in all its dimensions, through authentic accounts by experts in their fields.

Through various milestones since the introduction of allopathic medicine, the expansion of healthcare facilities continued in the absence of a grand vision, often in fits and starts, in response to the increased demand for better services by an aspirational population.

Amartya Sen, in his Foreword to HOP, points out that India’s allocation of a little over 1 per cent of GDP on public healthcare is appallingly low, about one-third of China’s. While lamenting the inadequacy of public discussions on this subject, he also cautions ‘The usual discipline of market incentives goes extensively wrong in the market for healthcare both because of externalities and asymmetric information, as Paul Samuelson and Kenneth Arrow … showed many decades ago.’ He stresses that health demands a kind of trust relation and quotes Arrow to say that ‘the very term “profit”… denies the trust relations’.

None disputes Sen’s prescription for a quantum leap in public investment. But the health administrators also have to work out innovative ways of spending the scarce resources more effectively and ensuring through enlightened policy formulation that private sector investment is synergised with the public to ensure better standards for all classes of our population.

Health sector is so crucial to everybody’s life that the vacuum created by collective state failure will automatically be filled up by private entrepreneurs and groups.

Therefore, blaming the private intervention as a corrupting influence promoting the rise of the medical-industrial (pharmaceutical and medical instruments industries) complex and decline of doctor-patient relationship to that of service provider-consumer may not provide, even if partly true, a fully nuanced picture.

Alluding to the European systems rooted in egalitarian traditions and the US system on libertarian ones, Sujatha Rao observes ‘India’s health system seems to be a confused one – articulated on egalitarian ideals but practised along libertarian principles’, notwithstanding occasional successes like in controlling the HIV/AIDS epidemic. Increasing cost of healthcare and its impact on India’s poor, both in terms of income depravity and well-being are also crucial policy considerations.

It has been argued that the charging of exorbitant fees by private medical colleges is one main reason first, for the poor quality of most medical graduates and second, for such graduates to resort to corrupt and unethical practices to recoup the money spent for their education. This is a serious issue, especially because private medical seats currently account for about 54 per cent of the total MBBS seats in the country.

It has been reported how practitioners, mostly in private hospitals, scare patients and compel them to undergo unnecessary investigations and procedures, prescribe expensive medicines and the like. Doctors allegedly receiving commissions from such referrals are also widely known. But to impute that corruption is the mainstay of the private system cannot be substantiated.

Government hospitals are known for their inefficiency and behavioural failure, and sleaze is not uncommon. In this context, to suggest that coverage of patients under health insurance is often intended to enrich the private medical and insurance institutions at public cost appears a socialist rhetoric. In fact, the latest government move in launching the National Health Protection Mission, with adequate budgetary provision, can be a game changer towards universal coverage.

The anatomy of corruption, at every level, has been exposed by the medical practitioners, journalists, activists, lawyers and public administrators, based on extensive primary and secondary data, in HOP. Nonetheless, success stories like the Banyan experience in Tamil Nadu or the examples of CMC (Vellore), St. John’s Medical College (Bengaluru) and the Mahatma Gandhi Institute of Medical Sciences (Sevagram) have also been highlighted, though more as exceptions.

The reader should not be misled by the term “predators” in the title; the editors while condemning the practise of profiteering from sickness also make it clear that medical profession has been affected like any other. “But healthcare is a critical and universal need” and hence perhaps deserves greater attention.

Evidently, the fight against pervasive inefficiency and greed has to be a long and continuous one. Enhancement of public expenditure, stressing as much on the preventive aspect as on the curative, improvement and standardisation of medical education [the idea of a common exit examination NEXT should be encouraged], establishing the National Medical Commission replacing the MCI, empowering state agencies to look specifically into corruption cases, declaring healthcare as a justiciable right and creating an environment for heightened public discussion on the subject are some of the steps to be taken if our record as ‘amongst the poorest achievers of good health’ is to change.

The writer is a retired IAS officer.