Paul Farmer in Pathologies of Power speaks evocatively of the crossroads at which humankind today finds itself. Healthcare, he observes, can be considered either a “commodity to be sold” or “a basic social right”. It cannot be both at the same time. Which of these pathways we will choose, he declares, is the highly consequential choice that people of goodwill must make “in these dangerous times”. He terms this as “the great drama” of our times.
As this “great drama” plays out in the world today, what choice are policymakers making?
The majority are opting for a significant, even paramount, role for for-profit private health providers in universal healthcare and the statutory right to health care. Their assumption is that the private sector will bring in efficiency, choice, high-quality healthcare and by bridging the resource gaps in public health systems, it will enhance the access of excluded groups. The result of these policy choices is a retreat of the state from direct healthcare provisioning, the crumbling of even the aspiration of a welfare state and the largescale transfer of scarce public funds to the private medical sector.
In this essay, I interrogate the legitimacy of these assumptions. The question I ask is whether there is not inherent in this choice of largescale public health provisioning by large corporate hospitals the potential for grave conflicts of interest? Is there not an intrinsic clash between, on one side, profit-seeking and, on the other, equitable quality healthcare that is based on need and not the capacity to pay?
A challenge literally of life and death for policymakers is to find ways to best bridge the massive chasms between health needs and health access, especially of the poor.
Thinktank Oxfam, in its briefing paper Sick Development, explains that a “poorly evidenced, but largely unchallenged, narrative has emerged that says extending healthcare to those most denied it can be done by funding for-profit, fee-charging healthcare providers and encouraging more private finance, including private equity firms, to do the same”.
The stark and unconscionable reality of our world remains one in which half the world’s population are still excluded from access to even the most essential healthcare. Sixty people every second suffer catastrophic and impoverishing costs paying for healthcare out-of-pocket.
These approaches of placing the life and health of impoverished people in the hands of profit-driven large corporations would be “deeply unpopular in European nations but are being exported to the Global South, with little democratic oversight and with significant taxpayer-backed budgets”, says the briefing paper.
What advocates of private health provisioning wilfully ignore is extensive evidence that for-profit private hospitals frequently block, bankrupt or even detain patients who cannot pay. Commercial and market-based approaches in healthcare can entrench and exacerbate the gap between rich and poor, and between women and men.
They also skew resources away from already under-funded government services while further excluding those who are excluded because they cannot pay or are socially oppressed. For-profit health providers lack incentives to prevent ill-health. Instead, the system hatches perverse incentives to misdiagnose or over-treat.
Policymakers and scholars do admit to the potential for conflicts of interests between profit and care. But the solution that we repeatedly encounter – as we did in our last chapter – is for robust and reliable regulatory systems for holding private health care providers accountable to high professional, ethical and equity standards. The argument is that if a coherent and legally enforceable robust ecosystem of state regulation, legal mandates, legal accountability, transparency and accountability is in place, these – with the active participation of patients and communities – can ensure that private health care providers are kept aligned with right to health goals.
This may sound convincing on paper. However, the reality is that accountability mechanisms on the ground are frequently found to be ineffective due to many reasons, such as weak implementation, fragmentation, and power asymmetries.
Even where formal mechanisms for transparency and accountability are in place, they often fail in practice due to institutional weakness, regulatory capture, legal ambiguity, and the concentration of power among private healthcare actors. State regulators may be underfunded or politically constrained. Courts may defer to legislative silence or interpret contracts narrowly. Local governments often lack autonomy and resources. Patients and families face barriers such as legal illiteracy, fear of reprisal, and inaccessible complaint systems. This is even more the case in low- and middle- income countries where the juggernaut of private corporate healthcare provisioning is most triumphal.
In a salutary way, Oxfam draws attention to the impacts of enormous inequality in power, status and information between provider and patient inherent in healthcare provision. What makes for-profit healthcare different from public healthcare is the perverse incentive for profit-seekers to exploit this inequality for commercial gain. “All of Oxfam’s interviews with patients and their relatives for this research laid bare the brutal reality that exploitation and extortion of patients and carers by for- profit healthcare providers are frighteningly easy, due to the universal willingness of human beings to make infinite sacrifices to save the life of a loved one”.
Besides this rare sense of empowerment of impoverished patients to hold doctors to account, effective regulation of the private health sector requires both resources and robust state capacity. Studies establish that these are scant in low- and even middle-income countries, therefore it is unsurprising that regulation in these countries is often found to be wanting. But the only reasons for weak regulation of the private health sector may not just be that they lack in budgets and capacity.
The even more fundamental constraints may be that there is little political will to hold powerful big business in check. And this may apply not just to low- and middle-income countries, but equally to rich countries. The reality of governments worldwide is of the formidable and ever-growing power of big business in policy making – of what Oxfam describes aptly as “elite capture” of the contemporary neo-liberal state; and, indeed, growing cronyism.
Such elite capture of policy making is pervasive and increasingly normalised. When Donald Trump was sworn in as President of the United States in January 2025, prominent among those in attendance were the world’s three wealthiest people – Tesla CEO and the world’s richest person Elon Musk (worth $433.9 billion), Amazon founder Jeff Bezos (worth $239.4 billion) and Meta’s Mark Zuckerberg ($211.8 billion). Their combined wealth was greater than the entire wealth of half the American population. The early months of Trump’s presidency – at the time I write this – is tarnished by the massive influence that Musk is visibly exercising on public decision-making in the world’s most powerful executive office.
The estimated value of the healthcare industry, including pharmaceutical and medical equipment companies, insurance and corporate hospital chains is a staggering $7 trillion. Health entrepreneurs are entering in growing numbers and power in billionaire lists of the richest people in many countries.
The president of leading health corporations in Brazil – Proparco and Rede D’or – is Brazil’s 10th richest billionaire. Ranjan Pai, controller of British International Investment-backed Manipal Group, saw his real-terms wealth grow by US$1.48bn in just one year alone. The cumulative impact of decades of neo-liberal policies is the effective transfer of power from public institutions to private enterprises.
Public health analyst Amit Sengupta regards that the state’s active role in facilitating the dominance of the private sector in healthcare not just a techno-managerial choice, but the wilful and wanton abdication by the state of its primary duties, by transferring responsibility for universal health care to the for-profit private health sector. Sengupta identifies what he calls “regulatory capture”, in which designated “experts” are drawn in by the state to assist and advise the state on the regulation of the very industries from which the “experts” are drawn.
Against the sobering reality of this landscape of the political economy of much of our world, I am troubled by the assumption that is still widely purveyed by policymakers globally, that states have the power, the capacity and the will to regulate the private health sector, to ensure that they promote the public good rather than private profits. I wonder how effective can we expect regulations and remedies in law to be to actually prevent the conflict between the duty of equitable health provisioning and the corporate pursuit of profit?
Oxfam, in its briefing paper, documents how in Kenya and India patients are imprisoned by private hospitals for not paying their bills. The statutorily mandated right to emergency care is denied. Treatment is impossibly expensive. Patients entitled to free care are instead pushed deep into poverty, being forced to pay high fees to access health services.
During the Covid-19 pandemic, some hospitals acted appallingly, profiteering even more than in normal times from people’s suffering and their fear of this new disease. Oxfam concludes that global and domestic taxpayers’ money is being ploughed into back expensive, for-profit private hospitals that block, bankrupt or even detain patients who cannot pay.
The report tells macabre stories of how a leading private hospital chain in Nairobi, Kenya, did not even release the corpses of patients who died for up to two years if the families could not pay the bills.
A newborn baby was held for three months for the same reason, and her mother would come each day to the hospital to breast-feed her. A schoolboy was held hostage for 11 months until his parents paid the bills.
In Nigeria, a normal child delivery costs as much as nine months’ income for the poorest 50% of Nigerians. A caesarean birth was even more expensive, costing as much as 24 years’ income for the poorest 10%. The bill for one patient who died from the Covid-19 virus in a private hospital in Nigeria cost an incredible US$116,000.
The bottom line is this: Consider a most powerless, excluded woman or girl child – suffering savage discrimination because of her race, caste, religion, sexuality or her undocumented status – who seeks life-saving healthcare from a highly privatised healthcare system dominated by giant and politically powerful corporate hospitals. Can she realistically rely on state regulation of giant private health providers to ensure stoutly her right to high quality health care so her life is saved?
For clues to this question, I will in this essay focus my microscope on the experience of one of the most privatised health care systems in the world, India. Some observers rate this to be the most privatised healthcare systems in the world, surpassing even the United States.
Why is it instructive to look closely at the functioning of India’s private and corporatised health system? The hospital industry accounts for 80% of India’s total healthcare market. India has one of the highest out-of-pocket spending levels on health in the world. Out-of-pocket spending as a proportion of total health spending is a leading cause of impoverishment in India. Thirty-seven per cent of Indians experience catastrophic health expenditures in private hospitals.
The abdication of the state in provisioning healthcare is spectacular. The Economist in 2017 observed that India’s extreme reliance on private healthcare is not ideological as much as the outcome of the reality that “government has done such a lousy job” of providing healthcare.
Over many years, India’s budgetary investment in public health has hovered from 0.8% to 1.1% of the country’s gross domestic product, among the lowest in the world. India stands fifth from the bottom in its public spending on health globally. And too little of even this paltry resource has gone into strengthening public health delivery and particularly into building primary healthcare. China invests three times this abysmal level.
In India’s mixed healthcare system, out-of-pocket spending and the market provision of services predominate. Only a little over a quarter of total health expenditure in India is borne by the state; the rest is out-of-pocket private spending and capital investments by the private sector. As much as 87% of private health spending is by individuals who lack insurance cover. Official data reveals that anything between 55 to 68 million people are pushed into poverty because of private health spending.
Private health care accounts for 80% of all health transactions in India. Eighty out of 100 trained doctors in India work in the private health sector (and this is after a significant number have migrated to countries of the Global North, earning high salaries that spiral further up the benchmark of aspirations of doctors who continue to live and work in India). India ranks 155th out of 167 countries on hospital bed availability. Seventy-two per cent of hospitals and 60% of hospital beds are in the private sector. Eighty per cent of all out-patient health services and 60% of in-patient health services are supplied by the private sector.
A quarter of a total of one million private health enterprises in India are middle to large medical establishments. In 2016, investments in private hospitals and diagnostic centres crossed 4000 million US dollars, including significant foreign capital transfers. Of 425 medical colleges in India, more than half are private medical colleges, accounting for 48% of all MBBS seats, with dizzyingly steep fees. They make large investments in land, buildings and equipment which they recover through sky-high fees. Naturally, the education they offer does little to prepare students for public service.
A common defence of private sector investments in health, often with international aid and financial institutions significantly contributing the capital for these, is that these fill gaps in public health systems resulting from low available public funds.
The Oxfam briefing paper First, Do No Harm, nails the disingenuity, indeed the complete falsehood of these claims. It looks at where large corporate hospitals funded by World Bank’s private sector arm, the International Finance Corporation are located. It finds that these private corporate hospitals have done nothing to bridge the access gaps suffered by impoverished rural populations.
For most private hospitals are concentrated in highly populated urban areas, and that too in the more economically developed states, because this is where more income and therefore profit can be generated. Seventy-eight per cent of the International Finance Corporation direct investee chain hospitals are in Million Plus population cities. Sixty per cent of hospitals are in Tier 1 cities, 35% are in Tier 2 cities and only 4% are in smaller habitations.
Of the 144 hospitals listed on the corporate websites of these chains, only one is in a rural area. Only 14% of the hospitals are in the 10 states ranked lowest in terms of the overall performance of the health system based on the Annual Health Index 2021; and not a single hospital operates in four of these 10 states.
Insurance helps create the mirage that unaffordable healthcare is actually affordable, although studies reveal that not more than 25% Indians can actually afford private insurance. And the net outcome of the state bearing the costs of private insurance of impoverished households is the transfer of scarce public resources to the private sector which arguably could have been better spent on strengthening primary healthcare in the public sector.
The near-complete absence of mechanisms to prevent the conflict of interest in public health policy decision-making (including privatisation and purchase of medical equipment) creates fertile ground for kickbacks and profiteering by health administrators and government doctors. This conflict of interest often veers decision-makers away from choosing optimal, rational and low-cost options.
To map, in some granular detail, how the private health sector actually operates in an environment of low regulation like in India, I will draw partly on inside accounts by seasoned health practitioners, teachers and scholars.
Seventy-eight such ethical doctors came together – many of them working in corporate hospitals choosing to be whistle-blowers – to reflect on the rot that has set into the vocation of health care. Their voices come together in a book titled Dissenting Diagnoses: Voices of Conscience from the Medical Profession, that should be compulsory reading for everyone seeking policy pathways to equitable and ethical healthcare.
A similar sombre account emerges from Healers or Predators? Healthcare Corruption in India. In this book, policy makers, practitioners and public health scholars examine the deep-rooted crisis of the consistent denial of basic healthcare to the overwhelming majority of Indian citizens.
I also draw from reports by Oxfam, a leading global voice for equity in health provisioning, particularly two that closely examine the functioning of private corporate hospitals established by global development aid and international funding institutions, in its briefing papers Sick Development and First, Do No Harm.
The picture that emerges from these searching and brave accounts by health insiders is sordid, terrifying and utterly unconscionable. We see how since the 1990s, in the “whirlwind” of privatisation, public health is consistently starved of funds and investments, and a relatively well-intentioned service-oriented vocation with the public health sector in the commanding heights is transformed first into a market-led commodity, and then into a corporate-led profiteering industry.
Pharmaceutical companies, medical equipment manufacturers, insurance companies, private medical colleges, international vaccine manufacturers, corporate hospitals and diagnostic centres, all join hands to convert health care into a high-premium commodity that becomes intractably inaccessible to the working and destitute poor.
It is not as though corruption was not rampant within public systems and does not continue to be so. But, as Kaveri Gill argues, in the public health sector, redress and reform are conceivably feasible if there is political will. Private sector corruption, on the other hand, appears beyond redress and redemption because corporate power is formidable, the spoils tremendous, corrupt practices pervasive and regulatory mechanisms feeble.
Senior health practitioner Mani also affirms that corruption also characterised public healthcare when it dominated the Indian health scene in the first decades after freedom. There were surgeons who would not operate on patients unless they first met then in their private chambers and paid them a hefty fee. Doctors employed touts in bus stands and railway stations to waylay patients and lure them to their door, for a commission. But he said these were in the past exceptions, condemned by the majority of the medical community.
However today such practices have become the norm. “We advertise ourselves”, he laments. “We employ touts to bring patients to us, we pay commissions to the doctors who send patients to us, we perform unnecessary and expensive tests and accept and even demand cutbacks from the diagnostic laboratories, we prescribe the most expensive of drugs and are rewarded for this by the pharmaceutical industry, and we even abet our patients’ efforts to defraud insurance companies. What will we not stoop to?”
Dr George Mathai, a physician from Alibag similarly grieves that “the very objectives and motivations for joining the medical profession have changed. Nowadays the only reason for joining the medical profession is to make as much money as one can, with as little work as one can get away with”. The personal conduct and ethical practice of doctors have hit new lows, as they prioritise profits over the welfare of patients. The social logic of “patients first” has given way almost fully to “profits first”.
Spurred and bribed by the pharmaceutical industry and owners of corporate hospitals, doctors prescribe unnecessary tests, expensive medicines and redundant, even harmful procedures, all at soaring costs with inflated bills. The result is that patients have to bear unnecessary, sometimes catastrophic expenditures because private hospitals have invidious links with drug manufacturers, pharmacies and middlemen of many kinds, including even autorickshaw drivers.
A senior and highly respected physician Dr Vijay Ajgaonkar bewails the many ethical distortions of the private health sector. Terminally ill 70- and 80-year-olds are kept in ICU and put on ventilators, even when there is no chance of their recovery, only to inflate hospital bills. In the process, they ruin the family and stretch the suffering of the patient. They don’t let him die in peace surrounded by his family members. In the ICU, there are tubes in his nose and mouth: he cannot speak even if he wants to. Even dead patients are sometimes retained on ventilators to further inflate hospital bills. Hospital agents converge like hawks at road accident sites to grab as many patients as they can. Doctors boast later about the numbers of “lambs” they have caught.
Ajgaonkar speaks bitterly of the bribes distributed by pharmaceutical companies, that include holidays abroad, expensive liquor, clothes, even expensive jewellery. The result, for instance, is that insulin that sold for Rs 30 rupees is now priced at Rs 150. Ethically the cost of research had long been recovered so the costs should instead have been reduced. Instead, the price is raised five times!
Many other doctors also report that medicines with no greater benefits than cheaper versions are widely prescribed to benefit the pharmaceutical companies. The companies make small changes in the formula of medicines that carry no additional benefit, then raise the price greatly while withdrawing the cheaper medicine from the market and encouraging doctors to prescribe the expensive version. There is no reason for ethical doctors to not prescribe only generic medicines which would cost them much less. Instead, doctors prescribe expensive antibiotics when cheaper ones would be no less effective.
The plunder of patients does not end here. Hospitals further mark up the costs of medicines in their bills to sometimes five or 10 times the maximum retail price. Even more egregiously, sometimes patients are administered much higher doses of medicines than are required, even risking the health of the patient. Likewise, patients are charged two to five times the price of coronary stents, and experts estimate that nearly a third of all stenting procedures in India are inappropriate.
“Doctors have now become servants of the pharmaceutical companies”, a physician observes dryly. Medical representatives take young doctors under their wings, benefit them materially and “retrain” them to adapt their practices in ways that maximise the company’s profits. They also draw doctors into bogus medical trials.
“One of the tricks played by the corporate hospitals is that they rarely give you a full prescription listing all the medicines”, a patient reported to Oxfam. “The nurse just gives you a slip. That way it is difficult to know the prices they are charging.” Oxfam finds that this problem is widespread in India. Its report refers to recent studies that found that profit margins for medicines, consumables and diagnostics ranged from 100%-1,737% in four of the largest private hospitals in Delhi, and that these items made up almost half the cost of patient bills.
It is noteworthy that the scandalously inflated costs of the doctor-pharmaceutical company nexus are borne entirely by the patient. The patient pays for the medicine, but has no control over the choice of the medicine. It is this monopoly over decision-making that a doctor possesses that is exploited by pharmaceutical companies to maximise their profits at the expense of the powerless patient.
The massive growth of multi-speciality corporate hospitals has metamorphosised health care into a highly lucrative industry. Hospitals have been reinvented from havens of healing and care to oases of luxury and privilege.
Gadre and Shukla observe that with its massive growth with liberalisation and expansion of the IT industry, an Indian city like Pune should have at least 50 public hospitals. It has only one. On the other hand, new, shining, multi-speciality private corporate hospitals are rising everywhere. They compare these aptly with shopping malls, which they resemble not just architecturally but in their business model. Just as malls have edged out small retailers that sold groceries and consumables, corporate hospitals have edged out the single-doctor practices and small nursing homes of the past.
“Hospital malls” have aggressively shifted the medical sector to the exclusive mercy of markets. Many of these private corporate hospitals claim to be charitable hospitals, which entitles them to concessional or free land and significant tax breaks. But in practice they rarely admit free patients, or if they are admitted, they are not respectfully treated.
Oxfam, too, records instances of refusal by private hospitals to extend free healthcare to patients living in poverty – although this was the conditions under which free or subsidised land was allotted to these hospitals. Poor patients also report to Oxfam instances of disrespectful behaviour by the staff of private corporate hospitals. “They don’t behave well to us when they know we are from the slum. When they learn that we are from the slum the hospital staff make us leave… We don’t take people there now… It is not for us. It is not for the poor families. It is for the rich people.”
Oxfam’s research also shows many cases of private hospitals unlawfully denying people emergency care, even though in India patients have a right to emergency care from all hospitals. For instance, a child was badly wounded and left unconscious by a traffic accident, but the private hospital denied treatment unless the family paid $1,200.
Unethical practices begin right from the stage of writing the prescriptions. The initial diagnosis that the doctor makes is wantonly graver than warranted by the patient’s condition, only to justify unnecessary diagnostics, drugs and procedures. Often there are no findings listed in the prescription, only the tests and medicines.
In corporate hospitals, patients are typically seen by multiple doctors and each bill the patient separately. There are no regulations or oversight about qualifications, or standard treatment protocols. Patients are also admitted to hospitals when all they need is OPD care. All a child with diarrhoea may need is the administration of ORH in their homes. Instead, they are admitted to hospital and given saline drips and a hefty bill at the end of this.
Oxfam also encountered shocking instances of medical malpractice and exploitation. For instance, a patient testified that the hospital staff said he had an 80% blockage to his heart and needed emergency surgery if his life was to be saved. He was sceptical, took a discharge, and consulted with a government doctor who repeated the tests and showed the diagnosis to be entirely false.
In another such instance, a man got admitted into a private hospital to have a problematic gallstone removed. The hospital ran several tests on him, including an ECG and echocardiogram to check the health of his heart. After the surgery the same tests were done, and doctors said he had an 80% blockage in his heart and that they would need to operate to save him. They even began treatment for this without his consent. It took the intervention of an influential local figure to secure his release. He then consulted a government doctor, who repeated the tests and then said to him: “Whoever is telling you that your heart is blocked is not telling you the truth.”
Oxfam also found grave cases of medical negligence confirmed by regulators even in the high-end World Bank financed corporate hospitals.
In one a patient is dropped on the floor leading to multiple fractures and death. Another dies because the patient is left unattended in an ambulance. In yet another death results because cotton wool is left in a patient’s brain after brain surgery. For one patient, the wrong leg is operated on, and for another a child is left permanently disabled. One baby is declared dead by doctors only to be discovered to be breathing as the last rites are performed. This on top of the widespread problems of overcharging, price rigging, and financial conflict of interest.
In corporate hospitals, investigations are not based on what the patient’s illness is, or whether the patient actually needs particular investigations. Doctors employed in large corporate hospitals are given targets of prescribing diagnostic tests even when these are not necessary.
Healthy pregnant women – to cite just one example – are pointlessly prescribed repeated hemograms, liver function tests and kidney function tests. Patients with confirmed diagnoses of depression are pointlessly prescribed expensive MRI and CT Scan tests. A gastroenterologist performs a series of endoscopies when only one is sufficient. Patients, influenced by marketing of corporate hospitals and diagnostic centres, themselves opt for “master check-ups”, most of which are unnecessary.
Ajgaonkar speaks of large public hospitals in Mumbai that have outsourced their radiology and lab departments to the private sector, only to benefit the private corporations. Pathologists also share that many pathological labs resort to what are informally called “sink tests”, in which the samples are just poured into the sink and a normal report sent. This can be dangerous for patients whose real maladies are missed.
Even more shocking than a superfluous test is when procedures and surgeries are prescribed that are not needed. A doctor confided that he was contemplating giving up his lucrative position in a corporate hospital. This was because of the pressure from the hospital management to deliver a target of 40% “conversions” of OPD visits to hospital surgery. His ratio was 15%. But he was caught in a dilemma. After studying so hard, he needed a job. And the only jobs he could find were in corporate hospitals. How long would he heed the voice of his conscience?
Another senior cardiologist also spoke of the pulls of his conscience that led him to leave his well-paid position in a corporate hospital where he was pressured by the management to recommend and perform unnecessary procedures like angioplasties. Another surgeon testified that often “totally unnecessary surgeries are done in corporate hospitals. For instance, a small gall bladder stone is causing no discomfort to the patient. But the patient is scared into surgery.
There are even shocking “pretend surgeries” in which small cuts and sutures are made with no actual surgery, but hefty bills presented. Gynaecologists report peers who are impatient with monitoring 14 to sixteen hours of labour and instead opt for a caesarean operation with a high bill.
A doctor explains it pithily, that first the hospital pays you a handsome salary, but then expects you to earn back that salary, even with – for instance – unnecessary kidney biopsies. Appendicitis and cataract operations and hysterectomies are performed when there is no need for these.
A surgeon speaks of his helpless regret when he sees how the bills for surgeries were inflated. The costs of surgery are routinely fixed in corporate hospitals at rates far higher than justified, but the patient has little choice, especially if beds and this surgery are unavailable in public hospitals. There is no regulation of what a doctor or hospital can charge.
For small procedures and surgeries, it is not uncommon to raise bills many times higher than what is warranted. The doctor cites the case of a very minor inguinal hernia procedure for which the patient was charged Rs 1.5 lakh.
Oxfam finds in low- and middle-income countries that the average starting cost of an uncomplicated vaginal birth delivery at a large private hospital amounts to over one year’s total income for an average earner in the bottom 40%. The cost of a caesarean birth amounts to over two years’ total income for the same person.
For an average earner in the bottom 10%, the starting cost for an uncomplicated vaginal birth at the private hospital rises to over nine years’ total income, and over 16 years for a caesarean birth. In First, Do No Harm Oxfam estimates that the cost of a two-day stay in a hospital in Delhi for a C-section is the equivalent of three to four months of Delhi’s average wage in Delhi-based IFC-funded Apollo, Max, and Fortis hospitals.
A doctor recounts the case of a man who died of a heart attack in a corporate hospital. They drew up an extortionate bill of Rs 16 lakh. His relatives could not afford it, so the hospital management resorted to the same strategy as the Nairobi hospital that I spoke of earlier. They hid the corpse. The police finally were called in to claim the body for the family. In another case, for a terminal and incurable case of cancer, the hospital prescribed an expensive and worthless regime that would impoverish the family long after the death of the patient.
Predatory over-charging reached even higher peaks during the pandemic. A large survey of over 2,500 Covid-19 patients in the state of Maharashtra found that private hospitals ignored government price cap with impunity. Seventy-five per cent of patients treated at private hospitals were overcharged by an average of Rs 1,56,000 (US$1,890). The research also revealed that average amounts of overcharging were far greater in larger corporate hospitals.
Public relations officers of corporate hospitals swarm doctors, offering them bulky “cuts” or commissions to refer patients to their hospitals. The practice of giving or receiving “cuts” or commissions for referrals to other specialists or diagnostic centres has also become routine.
Corporate hospitals institutionalise this by paying a portion of the money spent by a patient to the doctor who referred her to the hospital. Many hospitals pay 10%-15% of the total bill paid by the patient to the referring doctor. Diagnostic centres pay from 20%-50% to the referring doctor. Doctors frequently do not even record a patient’s history in any details. Instead, they just prescribe a set of investigations, for which they receive a cut or kickback. This is sometimes even more problematic in small nursing homes. Large corporate hospitals at least have rate-charts. In small hospitals, charges are often discretionary and therefore even more predatory.
Doctors and pathologists who refuse to participate in this morally grey zone of medical practice often find themselves with no work. Those who work in corporate hospitals report that their frustration that if they are scrupulous, their integrity does not benefit the patient who is still billed at levels that include the commissions.
Even other personnel connected in some way with corporate hospitals and nursing homes are also drawn into the embrace of “cuts”, even ambulance drivers and auto-rickshaw drivers. Late at night when relatives of a patient hail an autorickshaw to transport their patient to a particular hospital of choice, the driver refuses, insisting he would take them only to another hospital, one that has promised him a commission.
Doctors in smaller hospitals sometimes admit patients who they know they don’t have the competence to treat. They run up a high bill with the patient as her condition declines, then they refer them to corporate hospitals and harvest another “cut” from them.
Mani also describes many ways that doctors abet patients in unlawful ways. They certify fake illnesses to enable them to get leave or avoid a court appearance. Influential people soon after their arrest find doctors who certify that they suffer from grave ailments so they should be shifted from their prison ward to a much more salubrious hospital room.
Some unscrupulous doctors are also happy to abet for a high fee insurance fraud. The doctor records for the patient a diagnosis for a grave ailment from which the patient does not suffer, and bills expenses for expensive treatment that she or he did not receive. The reimbursement by the insurance company is shared between the patient and the doctor.
Independent research and testimonies of ethical insiders of the Indian health system strongly indicate that the mammoth expansion and domination of expensive private hospitals with feeble, even broken regulatory oversight or safeguards is, as summarised by Oxfam, “driving up healthcare inequality, diverting public funding and locking out opportunities for building truly universal and equitable health systems”.
This is because profit maximisation objectives in healthcare bring inherent risks to public health and patient rights. These have produced worse health outcomes and given less financial protection than similar investments in government-funded healthcare would have yielded. Worse still, evidence from countries like India shows that “by encouraging large-scale inclusion of for-profit hospitals, poor and marginalised people, particularly women, are being exposed to even greater risk of catastrophic and impoverishing healthcare bills”.
The wide claim of higher efficiency of private health provisioning is busted entirely by this disgraceful record of over-pricing, predatory marketing, and inappropriate medication, procedures and surgeries.
When maximising profits overtakes the healing and well-being of the patient, in the many ways we saw in this chapter, the private health sector no longer is the site of ethical treatment and care of patients. Instead, it mutates into a business for wealth accumulation by any means, many of these unethical and even unlawful.
One doctor observed wryly that corporate hospitals “maintain everything five-star style, but forget about the patient”. Another said that corporate hospitals want the doctor they employ only to earn them money. If the doctor wants to practice ethically, they have no place for him or her. And yet another – “there is no humanism to be found in corporate hospitals”.
I would evaluate the true worth of a health system by the respectful care it ensures to that most dispossessed and excluded woman or girl child who I started this essay with. There can be little doubt about one thing. And this is that the large shiny corporate “hospital malls” of our time have completely failed her.
I am grateful for research support from Rishiraj Bhagawati.
Harsh Mander is a peace and justice worker, writer, teacher who leads the Karwan e Mohabbat, a people’s campaign to fight hate with radical love and solidarity. He teaches part-time at the South Asia Institute, Heidelberg University, and has authored many books, including Partitions of the Heart, Fatal Accidents of Birth and Looking Away.
