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Sleazy medical practice in India: Is the doctor a prey or the perpetrator?

Nov 12, 2014

Unless the fees spent for the medical education is subsidizedor waived off, working in Government seems least attractive for doctors, writes Giridhara R Babu.

New Delhi: Recent news reports in leading newspapers indicate that profit and insatiable greed plague the private health industry.[1] However, the recent reports blame only the doctors for faults with the system including the excessive financial expenditure burden on patients. The unseen hands and brains driving the private health system are rarely acknowledged in the public discourse.

It is vital to understand the nature and reasons for exorbitant costspaid by the patients and to know the driversof the greedy practices. While the entire focus is on making the healthsystem more competitive and quality driven, is the country also ensuring a fairer and just way of administering the healthcare services to customers? This article is an attempt to reconnoiter the role of doctors in the entire spectrum of services in health system.

As the start of series of misfortunes, the entry into health system is gated by irrational capitation fee at private medical colleges.[2]The primary purpose of medical colleges should have ideally been obliging as the shrines of service,and instill nobility in budding doctors. Instead, the institutions turn them into businessmen who would have to get returns for their investment. Parents of prospective doctors have to shelve out nearly five to six million of Indian currency for mere completion of graduation.[3] Further, the post-graduation courses such as MD/MS costare costed greater than`10-15 million (~US$ 165,200). Simple maths will reveal that any college stands to gain nearly a billion Indian rupees annually if they manage to get 100 students in MBBS and 50 students in post-graduate courses (equivalent to 165 million USD).

Undoubtedly, construction of the building and recurrent costs are high but the unregulated profits are also astronomical. Therefore, it is not surprising that politicians, real estate tycoons and select businessmen have flourishing interests in managing the medical colleges in the appellation of “service to the community”. From the perspective of a doc who has spent nearly 1 crore on fees alone (at the minimum) for being a post-graduate doctor, the decisions taken earlier will change the course of life for ever.

Unless the fees spent for the medical education is subsidizedor waived off, working in Government seems least attractive.Oblivion to all this, the government expects the doctor to serve in rural areas in the government sector, with modest salaries. At the current rates of salary, no doctor can manage to save at least half of the fees paid even at the time of  retirement.

The doctors may therefore be able to have two options if they decide to work in India after their post-graduation.First, a great proportion of who work in UK are from India and get paid nearly 6 to 10 times more than the corresponding positions in India.[4]The economic implications compel them to choose the carrier path that pays well and therefore the second option represents working in the private sector. By default, these systems also havestandardized protocols for most procedures and practice evidence based medicine. Next choice is working with “for profit” private hospitals, wherein profit (in any of its avatars or labels) is the motive.

The assumption is that for having any “profit” in service sector,the system has to allow a margin between the operating costs and overall cost to the consumer.[5]It is concerning that such margin is huge in corporate hospitals in India, often hidden under several headings. Often, the margins of profits will have to soar high tosatisfy the gigantic greedof the system ensuing the unethical management practices.

Hence, numerous mendacious practices afflict the common man in the form of splitting of the fees among referrals and unnecessary investigations, wrong procedures and high costs of drugs. It is really an oxymoron that most of the private ‘for profit” sector is incompatibly positioned as a service diligence. The doctors and the patients alike are trapped in the spiteful cycle driven by profit oriented service sector.

What can be done? Will the Government do it?

*Regulate the private medical colleges and have uniform lower fees

*Regulate the private hospitals through legislations

*Standard investigation and treatment protocols

*Justified clinical and diagnostic examinations

*Decreasing the margin of profit

*Strengthening Public health system

*Have a Government superspecaility hospital in every district

*Have a state of the art speciality hospital in every taluk

*Every taluk/block should have best in the class Government run diagnostic facility, wherein all basic investigations are done

*Increase the salaries of doctors in public health sector

*Incentivize higher performance

Steps forward

By making salaries in public health systemstronger, India will not only ensure the presence of physicians in the most difficult and inaccessible areas but can also attract in bringing back many of the expat experts from all over the world. By improving the salaries of doctors, there is some extra undeniable expenditure on the system but this is by for a very minor proportion compared to the kind of exorbitant fees the poor will have to pay towards the health care benefits.  The golden eggs of the healthcare system cater to the greed of the management of the private medical colleges and for profit private hospitals.

he current status quo is maintained for decades due to several reasons including conflicts of interest of several ministers. It is important that Government regulates the private healthcare system to make it fairer and provide level playing platformto public health system. This can happen by bringing in norms and standard procedures including standard costs for all procedures. Autonomous models like Jayadeva Hospital in Bangalore have exemplified thepublic health system's efficiency and credibility.Better diagnostics and super speciality facilities can makegovernment centres more competitive and can indirectly regulate private sector. Can the current Government take bold decisionsto create fair and justified system?

(Giridhara R Babu is Associate Professor at Public Health Foundation of India. The views expressed are personal.)

References:

1. Berger D. Corruption ruins the doctor-patient relationship in India. BMJ: British Medical Journal 2013;348

2. Altbach PG. India’s higher education challenges. The International Imperative in Higher Education: Springer, 2013:163-66.

3. Kumar R. Healthcare and medical education reforms in India: What lies ahead? Journal of family medicine and primary care 2013;2(2):123

4. Rao M, Rao KD, Kumar AK, et al. Human resources for health in India. The Lancet 2011;377(9765):587-98

5. Bhardwaj SS, Chawla K. Exploring Competitiveness of the Indian Health Sector A Service Quality Perspective. Journal of Health Management 2013;15(4):535-47

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