Doctors in private practices across Karnataka have been protesting stringent measures in the Karnataka Private Medical Establishments (Amendment) Bill, 2017, which seeks to bring more accountability to the expanding private healthcare sector. The protests have resulted in the bill being referred to a joint select committee of the state legislature for more detailed deliberation.
The major point of contention is that the bill seeks to fix rates for medical procedures at private hospitals. A second point of contention is that the legislation has restricted the provisions of the bill to private hospitals and not extended it to government facilities. In doing so, it has set aside the recommendations of the Justice Vikramjit Sen committee, which was appointed in July 2016 to overhaul healthcare regulations in the state. The committee was of the opinion that there must be only one set of regulations for both private and public hospitals.
Former Karnataka Lokayukta Justice Santhosh Hegde has supported the doctors’ protests saying that he is entirely “against the government interfering in the affairs of private medical establishments” and that the “government must first address the pathetic state of affairs of the government hospitals”. His argument is however flawed.
Private medical establishments are not selling refrigerators and television sets. People are unlikely to sell their livestock, property, houses, jewellery to buy a television set. However if one’s child or partner is lying in hospital and one has to decide between a cheaper healthcare service with “less guarantee” of success and a significantly more expensive test or procedure that could have better outcomes, one would choose the latter even at great cost. This amounts to hospitals capitalising on people’s deepest fears and doubts and is unethical. Such “choices” are offered in most private hospitals.
Subverting government schemes
In private hospitals empanelled under the Vajpayee Arogya Scheme – a health assurance scheme for families below the poverty line – patients are offered free treatment under the scheme or “better” treatment for which they pay anywhere between Rs 10,000 and Rs 1,00,000. Patients admitted under the scheme have to pay upfront for procedures such as angiograms, which may or may not be reimbursed. They are not covered under the scheme for any complication arising out of the treatment or for any associated condition. Patients undergoing surgery under the scheme who develop stroke have to pay for the stroke treatment themselves. Patients who have heart conditions and an associated malignancy will have to pay for treatment of the malignancy, if it is not included in list of procedures under the scheme. Hospitals empanelled under the scheme have demonstrated how they can manipulate the government for economic gains, choose wealthy patients, while closing the door on patients who are terminally ill or requiring protracted care.
The composition of the Suvarna Arogya Suraksha Trust Board, which implements and monitors the Vajpayee Arogya Scheme, throws up clear conflicts of interest. Doctors from Narayana Hrudayalaya, the largest national hospital empanelled under the scheme, are also members of the board. An officer with the trust has agreed that that the scheme has been skewed in favour of Narayana Hrudalaya and hospitals for cardiac care.
The empanelment committee of the trust has come up with norms of service that could seriously impact the quality of care and patient outcomes, and which violate existing Medical Council of India and other guidelines. For example, it has permitted a surgical oncologist and radiation oncologist to administer chemotherapy. It has approved a gastroenterologist to perform oncosurgeries in violation of the Vajpayee Arogya Scheme guidelines that permit only onco-surgeons and ENT surgeons to perform head and neck cancer surgeries. When gross negligence and denial of care takes place, the private hospitals place the blame on the government that has put the scheme in place.
Public vs private
Karnataka has seen a massive growth of the private healthcare sector, which is neither self-regulated nor has allowed any form of government oversight. This has led to rampant overcharging, denial of patients’ rights, negligence, unnecessary procedures and tests. Government health services, on the other hand, have systems of monitoring and oversight, even if the implementation has generally been poor. They are much more accountable than the private sector when it comes to training guidelines, standard treatment protocols, reporting morbidity or mortality and referrals. Therefore, a market model of regulation does not apply. Government facilities in remote areas continue to exist even if they cater to a small population because their role is not envisaged as generating profits, but rather on principles of equity, accessibility, affordability and comprehensive care, even if they are riddled with inefficiencies in practice.
The clamour by private hospitals to bring in government hospitals into the ambit of the new law is not borne out of concern for the patient, but to ensure that there is a weapon to shut down even the existing government hospitals so that people are completely and absolutely at the mercy of an unscrupulous and unregulated market. The protesting doctors asking for implementation of the Justice Vikramjit Sen committee recommendations have failed to acknowledge that patients’ and citizens’ rights groups were excluded from the final decisions of the committee, leading to a complete takeover by private medical establishments that went on to the draft recommendations most lucrative for themselves.
Private hospitals have no mechanisms for reporting data on morbidity, mortality, caesarean sections, hysterectomies and other surgeries. There is poor documentation and maintenance of records explaining the rationale behind investigations and treatment, referral patterns and causes of death. Patients therefore have very little access to information if they would like to seek second opinions, which they are entitled to. The public health system has a more rigorous system of data collection and transmission, which helps to understand disease and mortality, as well as diseases of public health concern. For example, private hospitals have no strict protocol to report data on tuberculosis, HIV, malaria, dengue, Japanese encephalitis, caesarean sections, maternal mortality and vaccine-preventable diseases, leading to under-reporting of these conditions.
Lack of access to their medical information in private hospitals also makes it difficult for patients to pursue legal recourse if they suspect negligence. In cases of negligence and denial of care by private hospitals, expert doctors very rarely testify against colleagues even in open-and-shut cases. This leaves patients and their relatives at the mercy of these private medical establishments.
Sidelining poor patients
Another serious cause for concern is the burgeoning medical tourism industry. Doctors trained in India have already gone in large droves to foreign countries seeking professional and financial gains. Now, private hospitals empanelled under government schemes have trained their doctors on poor patients and are seeking patients from abroad who are willing to pay for treatment in riyals, dollars and pounds.
Private medical practice also needs to be regulated to curb the many clinical trials that are being conducted in which patients are offered experimental treatments without due process of informed consent or choice to opt out of such trials.
Health has been known to improve when the government health system is strong. Although Bangladesh, Vietnam and Nepal have lower Gross Domestic Products than India they have better public health expenditure and stronger health systems.
The government health system, apart from its curative role, plays an important role in prevention of disease, promotion of health, and rehabilitation. The private sector has never taken up the cause of preventive health because it has low economic value. While the doctors in the public sector undergo rigorous training on management of diseases of public health importance such as tuberculosis, HIV, non-communicable diseases, and dengue, the private sector has often initiated treatments that not only lead to bad outcomes for the patient, but create major public health problems such as antibiotic resistance, multi-drug resistance and other complications which are then left for the public health system to manage.
The government’s decision to regulate private medical establishments, introducing a charter of patients’ rights, creating a grievance redressal committee and fixing a cap on rates should be strongly applauded and supported. The government should not give in to the pressure exerted by the private sector lobby and instead do whatever is required to ensure that all patients, irrespective of their ability to pay, are offered access to comprehensive preventive healthcare, promotion of healthy practices, and curative and rehabilitative healthcare.
This would go a long way in making the government people-centric instead of market-centric, and make Karnataka a model of comprehensive health care for other states to follow.
The writer is a public health doctor and researcher.