THE PRIVATE MEDICAL SECTOR IN INDIA
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- THE PRIVATE MEDICAL SECTOR IN INDIA
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Summary of
The Private
Medical Sector
in India
Dr. Anan t Phadke
Foundation
THE PRIVATE MEDICAL
SECTOR IN INDIA
(Summary)
The private medical sector in India accounts for 61 % to 86% of
the total medical expenditure, 73% of allopathic doctors, a much larger
proportion of non-allopathic doctors, 56% of hospitals and 30% of hospital
beds, In spite of this dominant share that the private sector occupies,
there are hardly any studies barring those covering the drug industry which
have looked into its role and functioning.
This lacuna is especially glaring in the context of the recent trends
towards further privatization of medical care. In this paper, we have tried
to study different aspects of the private medical sector such as general
practitioners, consultants, hospitals, laboratories, medical colleges, etc.,
with a view to analyze how appropriate is this private sector in fulfilling
the health care needs of the Indian people and to find out what reforms
are needed to make it fulfill its role.
Though the private medical sector in India is more accessible to
and popular with those who can easily afford to pay for it, it suffers from
a number of features which are inimical to the interests of a rational,
affordable, socially desirable form of medical care system. These are socially inappropriate, costly, sub-standard medical education ; lack of
adequate, proper Continuing Medical Education; gross urban-rural disparity
in the availability of qualified medical practitioners; irrational dmg use;
unnecessary and unethical medical interventions; sub-standard quality of
medical care ; lack of rationalization of professional charges; paucity of
record keeping; lack of preventive measures and health-education;
unqualified, poorly paid paramedic staff; lack of professional self-regulation.
Many of these features are also present in the public health care system
but they are much more pronounced in Ute private medical sector. Each
of these problems is briefly examined below :-
I> Inappropriate Medical Education
Medical education in India is elitist, biased towards curative care,
hospital-oriented, wasteful and socially inappropriate. Private medical
colleges, barring exceptions, are no solution to these problems. Yet their
role has been increasing. The number of allopathic medical colleges in
India has increased from 28 to 125 from 1950 to 1987. During this period,
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the proportion of private medical colleges has increased from 3.5% io
17%. TXvclve out of eighteen new medical colleges opened during 19741986 were in the private sector. By 1986, the proportion of private medical
colleges in Ayurvedic, Homeopathic, Unani medical systems was 67%,
65%, 75% respectively. This proliferation of private medical colleges is
inimical to the interest of rational, affordable medical care for three
reasons:
1) There is no need to open new medical colleges anymore. Looking at
the current output from the existing medical colleges, by the year 2000
A.D. there will be one MBBS doctor per 2000 population and one doctor
of whatever degree, per 1000 population. Tliis ratio is satisfactory for a
developing country like India. Secondly, experience shows that merely
producing more doctors is not the solution for paucity of doctors in rural
areas; MBBS and post-graduate doctors tend to flock to the cities. Use of
well-trained, well-supported paramedics is the more appropriate solution
to the paucity of doctors in rural areas. Doclors from private medical
colleges increase the urban concentration of doctors since it is only in
cities that they can earn back their substantial investment in medical
education.
2) Private colleges charge from 3-5 lakh rupees per student. As of 199394, these fees are now standardized by the state - Rs. 1.72 lakh per year
for “paying” students ! Any doctor who has spent so much on education
is bound to recover it from his patients. Tliis can only be done by indulging
in excessive billing and unnecessary medical interventions, thus further
lowering the ethical standard in medical practice.
3) Most of the private medical colleges are sub-standard and arc not
recognised by the Medical Council of India .
Private medical colleges thus worsen the situation in the field of
medical education and hence need to be banned.
1I> Lack of Continuing Medical Education (CME)
v Unlike in some Western countries, a doctor’s registration in India
is renewed without undergoing any CME. There are voluntary efforts at
CME. For example, many branches of the Indian Medical Association
conduct CME - programmes for their members and IMA runs a monthly
Journal of Indian Medical Association (JIMA) for its members. But out of
3.5 lakh MBBS doctors in India, less than 25% are members of IMA, and
about 10-25% of die members attend its CME programmes. For the eight
lakh non-allopathic doctors (Homcopatlis, Ayurveds, etc.) there is hardly
any proper CME. Most of them prescribe allopathic medicines (“cross
prescriptions”) and depend more or less solely on the Medical
Representatives of drug companies for their knowledge of allopathic drugs.
As a result, the half-truths and untruths propagated by tire drug companies
are uncritically accepted by the medical profession.
A National Medical Education Board has to be set-up, which
would, through its state branches, deliver compulsory CME to doctors.
Renewal of registration of doctors should be subject to satisfactory'
completion of CME. Cross-prescriptions should be banned or should be
allowed strictly in accordance with proper training in the other palhy.
III> Irrational Drug Use
Most of the drugs marketed in India are in the form of drug
combinations and most of these drug-combinations are irrational and some
are even hazardous. Yet they are widely prescribed in India, especially in
the private sector. In the Public Health Facilities, the health authorities
draw up a list of rational, essential drugs and District Health Officers arc
to buy medicines in accordance with this list. The centralized purchases
of drugs in the public sector is therefore mostly of rational drugs. But in
the private sector, all kinds of irrational drugs are prescribed. This is
confirmed by the results of our study of prescription practices in a typical
district in Maharashtra. It was found that prevalence of use of irrational or
hazardous or unnecessary drug is far more common in the private clinics
than in the Primary Health Centres.
Unnecessary use of injections and intravenous infusions is the
most glaring and tire most common unnecessary medical intervention.
This, again, is quite common in private practice since there is a strong
financial incentive in unnecessarily using this costly mode of medical
interventions.
To remedy this situation, only rational drugs and rational drug
combinations should be allowed; all others should be banned. Along with
continuing education of doctors, there has to be extensive and continuous
health education of lay-people so that patients do not ask for injections or
“powerful medicines” due to their misplaced faith in them. A practice of
paying “examination fees” to a general practitioner has to be instituted
since lack of this practice is partly responsible for unnecessary use of
injections.
IV> Unnecessary and Unethical Medical Interventions
Unnecessary surgeries and laboratory tests are on the rise. This is
because of increasing urban concentration, increasing commercialization
and the rise of the corporate sector in medical care. To the list of
unnecessary removal of appendix, tonsils , uterus, etc., arc added new
high-tech procedures like heart operations. According to a senior heart
surgeon in Bombay, 40% of coronary angioplasties and 20% of coronary
bypass surgeries done in Bombay are unnecessary! It is quite common for
a C AT-Scan centre to offer commissions to doctors for sending their patients
for this costly investigation.
The sale ofkidneys for transplants; misuse ofprenatal diagnostic
tests for detection of the sex of the foetus and the subsequent elimination
of female foetuses; buying of blood from professional blood donors and
the consequent risk of spread of AIDS, Hepatitis - these murky deeds are
a special feature of the private medical sector.
These nefarious practices must be stopped with a heavy hand.
Standard treatment guidelines should be worked out by medical bodies so
that unnecessary medical interventions can be easily singled out.
V> Sub-standard Medical Care
Many private nursing homes neither have adequate floor space,
ventilation, cleanliness, or adequate water supply, nor well-trained staff.
This was recorded by a Committee bf the West Bengal Legislative Assembly
in 1985 and members of the Bombay High Court Committee in 1993.
The Nursing Homes Act is merely on paper, wherever it exists (as in case
of some of the metropolitan cities).
.. Minimum standards for private hospitals must be laid down and
strictly enforced.
VI> A rbitrary Professional Charges
There is no principled basis for the level of fees to be charged by
the doctor. The rule seems to be - charge as much as the patient can bear.
A pediatrician from a small town may charge Rs.20/- as consultation, as
compared to Rs. 100/- in a city like Bombay. Similarly, charges for
Caesarean delivery may vary from Rs. 500/- in a small town to Rs.5000/
- in Bombay. Doctors' charges should be standardized since an individual
patient is helpless to influence the doctor's fee. Cost of living, knowledge
and experience of the doctor, type of surgery - all these should be properly
considered to standardize charges.
VII> Paucity of Record-keeping
General practitioners and small hospitals keep (if at all) very cursory
and inadequate records of their medical findings, not to mention statistics
and proper accounts. Tire doctor's medical findings are not available to
the patients as a matter of right.
There is, therefore, no scope for any medical audit to evaluate
the performance of the doctor.
There must be minimum mandatory record-keeping by doctors
and it should be available to the patient as a matter of right, when he/she
asks tor it.
VIII> Lack of Preventive Measures and Health Education
Private practice, by its very nature, is confined to an individualized
relation between a patient and a doctor. So long as the patient is relieved
of his/her suffering, the job of the private practitioner is considered to be
over. But the disease process originates at a social level, e.g. defective
water supply to a community or promotion of tobacco. Doctors should
therefore participate in the collective action to control diseases because
they have the knowledge about these. But piivate doctors, by and large,
do not participate in the National Health Programmes like Tuberculosis,
Malaria, Leprosy Control Programmes, etc.
Similarly, curative, preventive, promotive health practices and their
rationale need to be propagated through health educational activities. But
private practice, by its very nature, tends to neglect these health educational
activities, especially on a social scale. This also holds true for the medical
profession as a body, although some exceptional doctors, through their
individual efforts, do undertake health education activities by writi ng articles
for lay people, giving popular talks, etc. The magazines published by IMA
“Your Health” and “Aapka Swasthya” (in Hindi) are not widely circulated;
in fact they are hardly known. Notable exceptions are the Diabetic
Association of India which, in some places, has been active for years
together in educating lay people about diabetes.
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The content of health education is also affected by lite needs of
private practice. On the one hand, aspects of science of medicine are
explained to the people. On the other hand, the overall impact of such
health education is to narrow down the concept of the disease process to
merely its biological aspects while ignoring lire broader social causes such
as environmental degradation or an unhealthy life-style. Secondly, such
health education mystifies medicine and exaggerates the importance of
doctors. In short, consciously or unconsciously, such health education
serves to expand the market of medical care.
Privatepractioners must participatein National Health Programmes
and in properly conducted health educational activities.
!X> Unqualified, Poorly Paid Staff
Most assistants employed in the private sector, except in big
hospitals, arc under-qualified. Given their low educational qualifications
and Ute very superficial 1 raining given by the doctors, most assistants cannot
cope with the responsibilities they have to handle. The quality of care thus
suffers. Due to long hours of work (in many small hospitals, the shift
stretches to 12 hours) and poor wages, poor avenues of progress, the staff
is dissatisfied and (his, in turn, adversely affects the quality of their work.
There is a need for proper education and continuing education of
paramedics in the private sector; also for some incentive in the form of a
share in the prosperity of the hospital or the clinic.
X> Lack of Professional Self-regulation
Medicine is not mere business. It is an honorable profession with
its own code of ethics and a statutory body (the Medical Council of India)
to uphold the dignity of the medical profession. Butin practice, the MCI
is quite inactive and ineffective in curbing irrational practices and
malpractices. Neither MCI nor the voluntary body-Indian Medical
Association-are regulating the quality of medical care or curbing unethical
practices in the medical field. Everything is left to the “law of the market”.
There has to be some effective mechanism of ensuring professional
standards and ethics in the medical profession.
XI> Conclusion
The above very brief survey of the pri vate medical sector in India
forces us to conclude that the private medical sector suffers from many
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serious problems and hence needs drastic reforms. The nature of these
reforms lias been indicated above, at tlie end of the discussion of cacli of
the problems pin-pointed. To reiterate these :
* ban on pri vale medical colleges;
* compulsory continuing education of doctors;
* ban on irrational and hazardous drugs;
* ban on cross-prescriptions;
* standardization of medical interventions, of
nursing homes and of professional charges;
* mandatory minimum medical record keeping;
* participation of pri vale practitioners in National
Health Programmes;
* proper training of paramedical staff and giving them a
proper share in the prosperity of the clinic/hospital;
* lightening of professional self-regulation by doctors’
associations.
'The Slate has to take a much more active role in enforcing these
reforms. Secondly, if the state pays for die medical care of its citizens, this
single, powerful buyer can enforce the above reforms much more
effectively. Patients arc loo vulnerable, powerless and scattered to put
any positive pressure on doctors to reform the medical system. Thus a
system of Universal Medical Insurance (UMI) in which every citizen is
automatically medically insured (the slate pays doctors’ bills for all its
citizens) is necessary to enforce these reforms. Such a system exists in
Canada and Australia and is eminently practicable. This publicly financed,
privately managed medical-care system would allow private practice and
initiative. But, at the same lime, it would also regulate it to safeguard the
interests of patients, of the nation and of rational, ethical practice in general.
A large majority of doctors would benefit from it because of the security
and tlie job-satisfaction it would provide to them. The question is, can we
achieve adequate political mobilization and political enlightenment to bring
about such a medical care system ?
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54l6re.
THE PRIVATE MEDICAL SECTOR IN INDIA
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8
Summary of
TIIE PRIVATE MEDICAL SECTOR IN INDIA
This is the summary of an overreview by Dr. Anant Phadke of
lite private medical sector in India. He identifies the following features of
the private sector which are an obstacle to the development of a rational,
affordable, socially just medical care system.— Costly yet sub-standard
private medical colleges, which are unnecessary in the first place: lack of
Continuing Medical Education of doctors: irrational drug-use ; widespread
" cross-prescription practices": unnecessary medical interventions ; lack of
regulation and standardization of quality of nursing homes and medical
interventions ; lack of preventive measures and health-education : gross
urban.rural disparity ; sub-standard, poorly paid staff, etc.... The author
suggests a number of reforms, which can be carried out ef*e''|ively in the
framework of Universal Medical Insurance, as has been done in countries
like Canada and Australia. These reforms are :*
*
*
*
*
*
*
*
*
ban on private medical colleges :
compulsory continuing education of doctors :
ban on irrational and hazardous drugs ;
ban on cross-prescriptions :
standardization of medical interventions, of nursing
homes and of professional charges ;
mandatory minimum medical record keeping :
participation of private practitioners in National
Health Programmes :
proper training of paramedical staff and giving them
a proper share in the prosperity of tire clinic/hospital;
tightening of professional self-regulation by doctors'
associations.
- The author argues that the inclusion of doctors in the Consumer
Protection Act 1986, would not improve tire quality of medical care If no
progress is made in the direction of these reforms.
Though the private medical sector in India occupies a dominant
share and position hardly any studies have analysed its functioning. With
the trend towards further privatizartion of medical services in India, this
critical study of the private medical sector stands out boldly. It should
interest -nvbody concerned with Ute fate of tire medical services in India.
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