In 1924, the Madras presidency of British-India rolled out the Subsidised Rural Medical Relief Scheme (SRMRS), which was about providing temporary annual subsidies to doctors choosing to settle down and practise privately in villages specified by local boards. Essentially a manifestation of the English laissez-faire policy, the scheme was then reckoned to be an economical way of expanding health-care access in rural areas. The economic depression of the 1930s brought this scheme to a complete standstill, and an initiative named Honorary Medical Scheme (HMS) received impetus. While initially planned to assist full-time permanent medical officers in government hospitals, honoraries soon started to supplant permanent doctors in an attempt to cut government spending on health. Eventually, any further recruitment into full-time permanent positions (expect in cases of exceptional need) was halted.
It is possible to deduce from what is sourced above, two noticeable and continuing trends that were directly inherited from colonial times. First that the spending on health shall be smooth to come under the knife at the slightest whiff of an economic downturn. Second, that laissez-faire will be the unannounced, yet predominant, approach towards health care, and the majority of doctors (and patients) shall be left to fend for themselves in an unregulated market. The current squabble over the Prime Minister’s recent purported remark about pharmaceutical companies bribing doctors with women escorts trivialises the deep systemic moorings of medical malpractices which lie in these trends.
Advent of the private sector
As early as in 1938, only 23% of doctors were in the public sector with the rest working in the private sector, predominantly in single practices. Post-Independence, perpetual sub-optimal investments in public health allowed the private sector to capitalise, flourish, and increasingly gain the confidence of the masses. The private sector went from having about 1,400 enterprises in 1950 to more than 10 lakh in 2010-11. To doctors, this promised greater professional liberty, lesser restrictions, and higher incomes. After liberalisation, the greater focus shifted to the lucrative tertiary-care sector and led to an onslaught of sophisticated private health care in cities.
The dominance of the market, bespoken by the simple fact that the private sector has over 70% of the health-care workforce and 80% of allopathic doctors, has meant that it is scarcely possible for a health-care provider to function in defiance of its norms. And the pervasiveness of malpractices in this market has come to ensure that few could survive without condoning them. Quite amazingly, players in this market, in much of their malpractices, have also learnt to function as a harmonious family. The family plays its role in safeguarding its members, acquainting them with its norms and interests, and leveraging the power of its patriarchs to defend its interests in society. It is little wonder that the market has also come to dictate the avenues of aggrandisement and yardsticks of professional success for health-care professionals. Business finesse and social adroitness rather than clinical excellence and empathy become the touchstones of calibre in this market.
Another way of describing things is that the larger chunk of Indian health care (and health workforce) could not be brought under a “national system” having some form of overarching state control or involvement — which could avail of essential health care without most people having to rely on a vagarious market, except as a luxury. The National Health Service of the United Kingdom, despite having seen a number of pro-market reforms over the years, remains the single largest health-care provider, employs nearly the entire health-care workforce, and makes essential health care available to all practically free at the point of service.
What this ensures is that the profit-driven private sector, the minor component, caters mainly to the affluent lot as largely a matter of deliberate choice rather than desperate compulsion. The Indian example, much like the United States’s, bespeaks the failure of the idea that a free market will compel players to be more efficient. Rather than increasing efficiency, the players have found it expedient to scrupulously exploit the prevailing cracks in the system and employ devious methods in order to maximise profits.
Health-care providers, just like others, are moulded by their social surroundings. When necessary controls are loosened, the connatural vices are let loose; when the habitat is conducive to values, the right traits develop. A system that starts off with health care as an overt tradeable commodity queers the pitch for virtues. Over time, a culture of exploitation and profiteering gets cemented, and the system gets locked in a trajectory that becomes difficult to alter. It is little wonder that in such systems, doctors require hefty incentives to stay motivated. Also, the medical profession attracts more of those with an ambition to earn riches than ones with an aptitude for medical service, thus leading to a generation of doctors who become the apologists of a profiteering system.
On the other hand, a system founded on the concept of equity (which, while remunerating doctors well, is able to separate incomes from patient care decisions by and large) cultivates a totally different culture of patient care. Doctors manufactured under its aegis cherish a spirit of service and hanker less for extravagant incentives. Things such as professional satisfaction and success come to be measured by a different yardstick, and there exists a different kind of motivation towards work, which is then bequeathed to the forthcoming generation.
Dr. Soham D. Bhaduri is a Mumbai-based doctor, health-care commentator, and editor of the journal, The Indian Practitioner. The writer acknowledges the contribution of V.R. Muraleedharan of IIT Madras from whose work some facts in this article have been sourced