Private and public health care delivery systems, despite their marked differences, suffer due to variable professional standards and limited accountability.
Health care in India, at its finest, matches the standards of international best practice. The knowledge, skill and confidence of its doctors and nurses, the sophistication of available technology, quality of service and five-star hospitality compete with the best in the world. Its relatively low cost has made it an important player in the health tourism sector. However, at the other extreme, publicly funded health care services often do not meet required standards, despite many committed doctors and nurses and the ideals, effort and money contributed by the National Rural Health Mission (NRHM). The regularity with which the media highlight scandals, report clusters of “unexplainable” deaths, expose dilapidated infrastructure, depict non-functioning medical equipment, record inadequate staffing and document negligence suggests a different world. Chalk and cheese.
These different systems reflect diverse philosophies and contrasting economic models: state-of-the-art private health care and capitalism, on the one hand, and public health care services with their inefficiency and socialistic framework, on the other. While many professionals in both these systems maintain the highest professional and ethical standards, many others fail to live up to the required norms of excellence and service. One often hears horror stories of exploitation and neglect. The variable standards of medical practice within each of these systems highlight similar problems, related maladies.
Professional standards: The contractual, legal and ethical obligations of medical practice and the public nature of health services mandate licensure and regulation. However, the Medical Council of India, a statutory regulatory authority, has never seriously engaged with nor regulated medical practice. Its powers to strike off doctors from its registers, suspend and withdraw licences remain on paper.
Professional societies also have an obligation to maintain standards of medical practice. Their role in establishing diagnostic and treatment protocols is crucial. Yet these societies focus on protecting the rights of their members, with little emphasis on responsibilities related to maintaining professional and ethical standards of practice. Their relationship with pharmaceutical and hospital industries often prejudices their concerns and moves them away from the science and art of medicine. Compulsory professional development and re-certification are unheard of in India. Professional groups rarely express convictions; they often push self-interest.
Audit and accountability: The maintenance of standards in institutions demands regular audit. Such audits are crucial to medical practice as they allow health professionals to compare their services with national and international standards, identify lacunae, change policies and programmes and update their knowledge and skill. Nevertheless, regular and systematic audits of processes and procedures are rare. Audits of input in the public sector and of income in private facilities take place, but without any focus on patient outcomes and cost-effectiveness. However, holding individuals and systems accountable for faulty policies and practice should be mandatory.
Culture of silence: The medical fraternity in India has its own omerta code. Even gross misconduct, often recognised by colleagues and superiors, is met with silence, complicity and even collusion. Corrections of major violations of conduct and poor standards of service are uncommon. This is true in both the private and public sectors. Tedious procedures, long delays, ineffectual committees, political interference, inconclusive investigations and the absence of action make people hesitant to raise concerns. Instances of gross medical negligence and less-than-optimum care are often covered up, leading to perpetuation of such practices with these becoming the norm. The medical fraternity usually circles its wagons in the face of public scrutiny instead of opting for transparency, investigation and improvement.
Society in transition: India is in the early stages of transition from a feudal society to an enlightened social order. The power differentials between doctors and their patients, the unequal knowledge base, the supply-side/seller's market and paternalistic attitudes within the medical profession do not allow for the empowerment of patients. Complex decisions are often made for patients without their adequate understanding of issues, resulting in their minimal contribution to the decision-making process.
Dissimilar impacts: The lack of standard guidelines, poor execution of simple regulations and non-existent audits of medical practice play out very differently in the private and public sector health delivery systems.
The NRHM and its many innovative platforms have increased access to, and availability and affordability of health care in many rural areas. Yet, many health centres, despite improvement in infrastructure and personnel, perform poorly in providing basic health care. The lack of professional development, low professional standards of practice, poor supervision of processes and the lack of accountability in public sector hospitals result in sub-standard care. Although the Janani Suraksha Yojana has increased institutional deliveries across the country, maternal and infant mortality continues to be unacceptably high in many regions. Audits have shown a failure to adhere to recommended treatment protocols. The absence of routine institutional audits, despite being part of the system, results in a lack of accountability. Self-regulation does not work. The culture of silence and feudal social systems results in poor quality of health services.
The context of the private sector is very different. Educated and well-heeled patients demand higher quality of health care. Failure to implement professional standards under these circumstances often results in over-investigation of patients and the use of multiple, inappropriate and expensive medication/procedures. Remunerations based on commissions distort medical practice. It is easy for bias to hide out in the fog of medical jargon, technology and decision-making. It is not difficult to befuddle patients with jargon and baffle them with technology. Even discerning patients are unable to recognise inappropriate practice and curb inflated health care costs. The prevalent neo-liberal culture focusses on the trappings of sophistication, technology and hospitality rather than on the quality of medical decision-making and therapy. The absence of medical audits, despite routine and rigorous financial reviews of performance, makes for poor health care. The culture of silence renders the exposure of incompetent or unscrupulous doctors rare. Self-regulation does not work.
The choice for patients should not be between poorly functioning public hospitals and exorbitantly priced private health care. For a majority of Indians, choosing between the devil and the deep blue sea is no choice at all.
Moving forward
While many doctors work against the odds to maintain the highest professional and ethical standards, many others fail to live up to what is required of them. While one tends to blame individuals for failures, the problems in reality, are systemic. Private and public health services need regular audits to maintain professional standards and to establish individual and collective accountability. The neoliberal creed of greed in private and corporate practice and apathy in the public sector mandate regulation and supervision. External enforcement of accountability (e.g. redress through consumer courts and the Common Review Mission of the NRHM), although necessary, has not delivered and cannot deliver quality care. There is need for regulatory authorities, professional societies and institutions to implement standards through mandatory protocol-driven management guidelines, to change their culture and enforce basic minimum standards. The publication of such protocols will democratise knowledge, allow for comparisons, assure quality and curtail costs. Display of audits carried out within institutions (e.g. microbial antibiotic resistance patterns, Caesarean section rates, etc.) will inform citizens of the issues involved and allow for informed choices. A regular review of individual and institutional performance is mandatory. Continuing professional development and re-certification are necessary. Empowerment of the general population and its participation in decision-making are crucial. Grievance redress mechanisms should also be in place. There is need to strengthen governance at the institutional level.
Strong advice with a weak audit of practice will result in variability of performance of individuals, institutions and systems. Although it sounds blasphemous, the “Interest-Convergence dilemma” is obvious. The idea that doctors, despite their stated aim, would not always support efforts to improve the lot of patients, unless it is in their own personal interest, is not hard to see. The brightest of individuals and the best of systems need a regulatory framework to produce consistent results and maximise benefits for all. A significant proportion of doctors have yet to buy into the need to follow standard algorithms related to health care. Ideals are easy; living up to them is not. The culture needs to encourage individuals and institutions to take responsibility, update their practice and be accountable. Self-righteous defence is not an option. However, there are no black-and-white victories in such battles, only incremental ones. The proverbial two steps forward and one step back. Health systems in India have a long way to go before ethical and scientific practice is the norm rather than the exception.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. The views expressed are personal.)
Keywords: public, private health
In this era of heavy professionalism and aggressive marketing, the
professional ethics/conduct and standard moral values etc.. have taken
backseat, saint like good professionals are lost and mostly remain
unknown and on the other hand incompetents having high degree of
commercial attitude are ruling the roost. Whole scenario is chaotic
instead of being systematic, good luck and good fortune are saving
people from misery and misfortune. Govt. is totally apathetic on these
issues. With growth in population crowd in hospitals has increased in
manifold.
At entry level in medical colleges good candidates be encouraged.
Unscrupulous elements have dented the image of the profession
Health care is a broad topic by itself.In India we have a great scope to improve it.The few things that could do with some improvements are public health,medical council of India,research and acute medical care. The article has raised various issues faced by our hospital health care system.I believe each of us have a moral responsibility in making the system better both public and private. We all should strive to live healthy,this by itself reduces the work load on the hospital system.Learning about health and illness and participating in decision making about our own health during medical consultation improves health care systems. I will just add on to the above article to say that the medical council and ministry of health should encourage and support the local hospitals(both private and public) to conduct quality medical research and help the government or professional bodies make policies and protocols based on scientific analysis.
Sir,
Excellent article-highlights issues and suggestions succinctly. A key
aspect in my experiences from India and now in the US is lack of the
culture of audits (quality/outcomes based research) ie what did we do
wrong and what can we do better; Additionally most Indian trainees
read US or UK guidelines - due to lack of good, applicable guidelines
in India. These are written with a different set of health problems
and a different budget in mind and should not be extrapolated to
India. This atleast in part is the reason for driving up costs in the
private sector. With our strong culture of clinical medicine it is my
belief that in such low-cost, high fidelity Indian guidelines lies the
potential to reduce exploding healthcare costs not only in India but
the world and the ability to expand coverage.
Einstein said " Failure is doing the same thing over and over and expecting a different result". The Govt is spending money on public health but not getting the deserved quality result. The solution is to privatise the public health via bids to private hospitals to run them more efficiently on a " fixed" budget. In most public clinics the doctor or staff may not just show up but still collect their pay. In a private setup they will be fired. The role of the Govt should be to maintain standards and ethics.
We have this wrong notion that longevity in the advanced countries is all because of advancement of medical science, chain of hospitals and the insurance corporations behind it. Whereas the fact is that longevity in advanced country is because of improved living conditions. To think that elaborate chain of hospitals and the insurance system will improve the living condition of people by contributing to economies is wrong. The biggest contributor to the deficits and debts in US is the Medicare liability. When insurance has to pay to the Health care of the sick then cost of this care keeps going up. India had the best chain of Government hospital and medical colleges till some of the entrepreneurs in the field in collusion with the political establishment worked hard to prove that Government was not capable of running hospitals. The result is that we have some good medical colleges and good hospitals. But if we allow insurance to step in as middle man between the sick and the medical fraternity then we will be doing justice to neither as we see in US. Let the patient and the hospital negotiate the price of care rather than give this to the greedy insurance corporation which takes away a big piece of the pie under the alibi of research which again is the domain of doctors and not the insurance industry.
A brilliant article. Thanks doctor.
The article is well written but intially paints the most perfect private sector.Best of learned men and women can easily be ripped of their money. Above all doctors most time,take time to intiate investigation but do not seem explain the results even, for that matter not even the primary issue. Initiating audit is good but the thrust should come from Regional Governments and Central Governments(Poltical Muscle) and one cannot expect by individual initiative. As rightly pointed out earlier the country healthcare is run by quaks in most places and therefore Recertification is far fetched for now. A very simple initiative to keep our surroundings clean in particular public places, would be ideal simple step towards better health. If governments are commisoned to focus on Clean water, Proper disposal of waste and efficient transport means it would make us spend our money for other aspects of life. India interms of Maternal And Child Health is a developing poor country leave alone the rest
Well written essay encompassing all the different facets of why medical system in India is not working as well as it should. However, there is no mention of specifics or metrics to improve the system. It seems like lot of hand waving. In the end, you are just lost and get the feeling that nothing much can be done to remedy the situation.
Example of greed: My two sisters-in-law were operated on for laparoscopic cholecystectomy after single episodes of abdominal pain, even when their gall bladders had contained moderate sized solitary gall stones. About 2 years back a surgeon was penalized in Texas for this mode of treatment.
Cutting corners: A neighbor of mine had an inoperable cancer involving the apex of left lung. It eroded his two upper ribs and caused severe pain from entrapment of brachial plexus. Recommended treatments in such setting include irradiation without waiting for biopsy. Oncologists of a Kolkata teaching hospital treated him with chemotherapy at one sitting and discharged him at afternoon. He died at the same night.
Use of kitchen remedies: A septugenerian with hypertension had one episode of vertigo. For next ten years she was treated with daily dose of phnytoin with periodical X rays of her neck. The attending physician did not perform a caloric test and never examined for a nystagmus.
Sir,
Well written. The professional bodies in India should change their way of functioning which at present aims to increase their members' interests alone. They should fulfill their responsibility to the society by demanding & imposing professional and ethical standards from their members. But even the discussion is missing. The meetings only discuss how to increase their perks and how to prevent regulation. Medical ethics often takes a back seat.
It's high time the Government brings forth standard protocols suitable to our needs.The unholy nexus between medical professionals and the pharmaceutical industry should be curtailed.
However this lack of accountability and apathy is not just confined to the medical sector, but pervades the whole system.
To counter this disturbing fact we need not just committed professionals, but also an enlightened Government led by idealistic and empathetic politicians who will act in the interest of the masses rather than protecting corporate interests.
What works for America may not work for India. The crux of the problem is the utter negligence of the government hospitals by the government,doctors without conscience and the vested interests who do not allow cleaning up of the Augean stables. The affluent can afford quality medical care whereas the man-eater private sector has been squeezing people to the utmost. even middle classed are feeling dread to visit corporate hospitals to cure any small ailment. Accountability to the public, avoidance of bribery and social and ethical consciousness can alone redeem the the millions who are desperate for health care at affordable cost.
Again a very much appreciated piece of article listing the guidelines
to improve our Medical system both in Public and Private care.I hope
some policy maker and administrator will listen to these suggestions
and will improve the dire state of dilapidated Health and Medical
facilities.Values ,ethics,accountability and dignity have clearly
taken a dive dip in highly admirable Medical profession.The whole
emphasis is on making bucks and at the same time large incentives in
private practice in the much dominated private healthcare(around75%-
80%) of total healthcare has allured the attention of public
healthcare.As rightly pointed out by one of the commentator that
building of social character can make a difference to accountability
part and is the driving point in any prosperous and intellect
society.I remember one of esteemed and highly respectable doctor in my
society.He worked from 6am to 11pm everyday and taking a charge of RS
1 for his service.You will rarely found these people today
A very good article, It gives me pleasure to note that doctors from Christian Medical College Vellore often write in Hindu. Corporatization of health care in one hand improved the health services in quantity and quality but also make it unaffordable for majority of the people. There should be proper audit of money extracted by private hospitals from the patient who due to unawareness about the disease and diagnosis or due to the criticality pay whatever is demanded. It is rightly pointed by Dr. Jacob that self regulation is not enough, and with the degrading moral standards of the society doctors are no exception. we have come to the stage where we need some law enforcing agency who can force us to be ethical and perform our duty. Strange.
'Social charter' is the key word to have a sustainable and workable health system as is proven in several countries like the UK, Australia and New Zealand. Apart from adequate funding for the system in terms of committing at least 5-6% of GDP to get decent infrastructure, it needs the social thinking and humanity to sustain the system. All workers from the doctors down to the orderlies should have the dignity of labour and mutual respect for the system to work. Further, moral standards will mean that each employee feels proud to belong to the system and will point out if there are people not maintaining standards. Most systems that work depend on levels of accountability and dignity of labour. This philosophy is not seen even in the private sector yet. Medical students are not taught the principles of ethics and to care about colleagues and other health workers irrespective of position and status. Working in New Zealand for the last 20 years has shown me that the dignity is the key.
One of the reason why health care in government set up is lagging behind times is because people invariably land these jobs because of political influence and once a person is sure of his posting he/she knows very well that it is very difficult to displace them. Therefore they have no qualms working for less number of hours or worser refusing to treat patients or teach medical students. This is a cycle which continues because students who are not provided proper guidance seldom rise to standards where they can do justice to the patients' under their care. one more reason is the arbitrary manner of government postings which lays more emphasis on seniority rather than the merits of a candidate while considering a promotion. This leaves no incentive for people to update themselves with the latest in the medical science resulting in sub standard levels of patient care.
Excellent article..Thanks Jacob for putting the thoughts. I am baffled with the corporate culture of hospitals and the way they are charging money. A fever ailment is costing 20-30K in the hospitals in the name of tests scans hospitalization etc which does not make sense at all. This puts lot of population at risk of getting good health care. Often when speaking to friends hearing them out makes me feel, the doctors today have no moral grounds or ethical code of conduct as they too are advised by their corporate bosses to squeeze money from the patient as much as possible. If in 2011 it's the case, then I think the future is not so bright and the haves who can afford can get medical advise and others not
Dr Jacob's analysis though excellent misses out one very pertinent reason as to why care in most of the government run hospitals is so pathetic. This reason is 'private practice'. At most of state government run hospitals across most states of India, private practice is allowed. Most clinicians indulge in this to boost their professional income. On paper,private practice should not come in the way of managing patients who are admitted under the clinician's care. But, the reality is totally different. Private practice within the government set up allows specialist and even senior consultants to show less than required commitment towards the poor patients in their own wards.Plenty of reasons are quoted by doctors for continuing to still do so ranging from poor salary, poor perks, poor facilities etc.At the end of the day however, it is always the patients at these hospitals who suffer. The solutions have always been there but vested interests will see that this never is implemented.
Very well written. Hope Medical Council of India, and the Union Ministry of Health take some concrete steps.
I am left breathless by this beautiful OP-ED. I have never been able to synthesize all the issues and pieces related to health care quality in my mind. Thank you, Prof. Jacob, for writing such a wonderful article. I love the fact that you end your essay with not just listing the problems but suggesting ways we can move forward in an incremental manner. The only thing I would emphasize is that in addition to increased transparency, measuring quality of care, and public reporting, we also have to move toward a performance-based payment system (especially in the public sector) where medical professionals and facilities are reimbursed based on the value they add. For all this to occur, as you so clearly laid it out, it has to start with standards and collecting and reporting quality of care information in a transparent manner.
Dr Jacob is aiming for a western style of functioning in Indian Hospitals. But he fail to recognise the reality in medical practice in india. In a country where quacks outnumber the qualified practitioners, how to regulate them. A quack (who doesn't know where is the Liver located and what is the function of heart) would be allowed to practice uncontrolle, but the qualified doctor who will be better than the quack should be erased from the register is not practical. At the same time I am not supporting the way in which we practice medicine in India. The change should start happening now. Govt; has the responsibility in performing audits for all common diseases to start with and than uncommon diseases. Protocols and guidelines should be formed by the professional group such as API,ASI and specialty forums to suit Indian needs not just to copy the european or American guidelines.Atleast if we practice medicine as per guidelines in india a lot of death could be prevented.
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