Given that India is currently quite dependent on the private healthcare sector, the lack of effective regulation and standardisation has widespread consequences which affect every segment of society. The Government of India has been receiving many complaints regarding malpractices in private clinical establishments, particularly large multi-specialty hospitals and corporate establishments. Patients admitted in hospitals are often forced to avail of in-house diagnostics services and to purchase medicines, consumables and implants from select vendors. These are sold with hefty profit margins ranging from 100 per cent to 1,737 per cent according to a study by the National Pharmaceutical Pricing Authority (NPPA), Government of India.
Lack of Standard Treatment Protocols leads to widespread irrational and unnecessary treatments, tests and procedures. Vulnerable patients and their families complain about lack of transparency in treatment, of medical negligence, violation of the patients’ rights and the frustration of facing an opaque and biased system of redressal, which often does not give them justice. The health-care sector is disproportionately prone to market failure, which can only be curbed by effective and comprehensive regulation in public interest.
It has long been recognised across the world that the delivery of health care should not be organised as a purely commercial activity, dictated by the market. The Nobel Prize-winning economist Kenneth Arrow had warned over half a century ago that in the realm of health care, competitive markets generate inefficient allocation of resources, leading to market failures; non-market institutions are necessary to compensate for these. Policymakers in India have nevertheless conveniently turned a blind eye to this lesson over the last several decades. Here it is relevant to note that without ensuring mechanisms for effective regulation of private health care, the Union government launched the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018, an insurance scheme covering costs of secondary and tertiary care up to Rs 5 lakh for 10.74 crore of India’s poorest families, based on the public-private partnership (PPP) model for provision of health care.
Now more than ever, regulation of health care cannot be just left to groups of private medical professionals who dominate medical councils. The reasons for their inability to self-regulate is evident. Strong stewardship by state institutions, combined with effective frameworks for social accountability are necessary to reinstate the “social” logic, which must prevail over the dominant “profit” logic in the contemporary health system. Effective regulation, social accountability, and transparent governance regarding private health-care providers are key steps to ensure that health care moves in the direction of becoming a public good, free from the dictates of commercialisation.
The past decade has witnessed growing support and activism among civil society organisations and ordinary citizens in India for building accountability of the private health-care sector and protection of Patient’s Rights. Networks like Jan Swasthya Abhiyan (People’s Health Movement–India) seek to mainstream the discourse on social accountability of the private health-care sector. Books such as Dissenting Diagnosis (Gadre and Shukla, 2016) and Healers & Predators – Healthcare Corruption in India (Nundy, Desiraju and Nagral, 2018), authored by senior healthcare professionals disturbed by the increasing commercialisation of medicine in India, are powerful “insider” accounts of prevailing corruption, malpractices and profiteering in the private health sector in India. These books have initiated a debate on the reality of commercialised medical practice and have motivated sections of ethical doctors to come together to advocate for accountability in the private health-care sector through various platforms.
Civil society networks have supported citizen activists like lawyer Birender Sangwan, who filed a PIL in the Supreme Court to regulate the price of exorbitantly expensive cardiac stents in 2014, leading the National Pharmaceutical Pricing Authority to bring down stent prices by over 70 per cent in 2017. The family of patient-victim Adya Singh, who tragically lost her life after treatment in a large corporate hospital accompanied by grossly inflated bills, has started an organisation called All India Patients’ Rights Group. Such voices are strengthening the impetus for regulation of the private health care sector in India.
If private resources are to be harnessed for public good, then the state may have to consider moving beyond formalistic “enforcement” and instead using an “interventionist” approach towards regulation. This would restructure the market to align with national health goals and priorities, while ensuring accountability of the private health sector with a mix of legal, financial, and social regulatory tools. Regulation of the private health-care sector should include the following measures in the near future:
1. Effective implementation of the Clinical Establishment Act, 2010, and similar state-specific legislations after notifying Minimum Standards. This should include regulation of rates, transparency in pricing and compliance with Standard Treatment Protocols applicable to all health-care institutions.
2. Mechanisms to enable health-care professionals and facilities to comply with regulations, through:
• adopting a differential approach and providing additional support to smaller, rural and genuinely not-for-profit health-care establishments;
• awareness and capacity building of providers, especially in the initial stages, to overcome their distrust and biases in public regulation;
• providing some transition time to meet infrastructure and human resource standards, depending on their category and ability to meet costs of regulatory compliance.
3. Implementation of the Patient Rights Charter in all public and private hospitals, along with establishing patient-friendly grievance redressal mechanisms at hospital, state and national levels for victims of medical negligence and malpractice, which are committed to timely and fair resolution of disputes.
4. Staffing regulatory agencies with adequate human power and resources, building their institutional capacity to implement and monitor regulations.
5. Ensuring that the regulatory agency responsible for developing health care prices in the private sector will adjust them for fairness (keeping in view geographical cost adjustments, need to ensure health care access to under-served populations etc.) and revise them periodically. The government should also ensure that stakeholders like medical associations can provide feedback and give inputs in the price setting process, to avoid potential stalemate situations.
6. Promoting social accountability through creation of multi-stakeholder governance platforms at all levels of governance including district, state and national levels. These would be representative of key stakeholders and should include patient groups, civil society organizations working on health rights, health workers’ associations, women’s organisations, as well as associations of medical professionals. Such participatory governance of health systems will ensure equitable access to health-care services, minimies malpractice due to monitoring of performance and ensure that all stakeholders have a voice at the table.
Excerpted with permission from “People over Profits: Reshaping India’s Private Health Care” by Abhay Shukla, Shweta Marathe and Kanchan Pawar, from Dreams of a Healthy India: Democratic Healthcare in Post-Covid Times, edited by Ritu Priya and Syeda Hameed, Penguin Inda.