HEALTH CARE SCENARIO IN INDIA PRESENT AND EMERGING
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HEALTH CARE SCENARIO IN INDIA
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HEALTH CARE SCENARIO IN INDIA
PRESENT AND EMERGING
Dr. C.M. FRANCIS
1. INTRODUCTION
Each civilization – Indian, Egyptian, Babylonian, Greek or Chinese – had its own
way of attaining and maintaining health and tackling disease. The Indian Systems
of Medicine included Ayurveda (the Science of Life) with the principles and
practice of healthy living, Siddha and Unani. And then came Western (Modern)
Medicine, with the coming of the Europeans. Western Medicine has been greatly
influenced by Greek and Arab Medicine. Next come Homoeopathy. All these
systems are flourishing today. Will they be integrated? That is the million dollar
question.
Hospitals came into being in India quite early. During the Maurya and Gupta
dynasties, there were hospitals for men and animals. Emperor Asoka had built a
number of hospitals. Veera Chola Maharaj had built many hospitals and even a
medical school. Emperor Akbar had a number of hospitals built, including a large
one at Fatehpur Sikhri. All these were free charity hospitals.
The first Western (modern, allopathic) hospital was built in 1510 A.D by
Albuquerque – the Royal Hospital – in Goa. The East India Company built
hospitals in Madras (Chennai), Bombay (Mumbai) and Calcutta (Kolkota). There
were separate hospitals for the Europeans, the Sepoys and the ‘natives’. The
condition of the hospitals for ‘natives’ was extremely bad. One visitor wrote :
“The Company has a pretty good hospital at Calcutta, where many go to undergo
the penance of physic but few come out to give an account of its operation”. So
much for the quality of care and the outcome!
The twentieth Century saw substantial numbers of doctors, nurses and allied
health professionals coming out of the teaching institutions and the establishment
of many more hospitals.
Independence.
There was greater growth after India attained
The major increases were in the Government and Voluntary
Sectors. There were also large numbers of private, general practitioners and a few
nursing homes, catering for the middle class families. The quality of service
(especially nursing care and cleanliness) was much better in the hospitals in the
voluntary sector. Towards the last two decades of the last century, there was a
spurt in the number of nursing homes and hospitals in the private sector.
There have been qualitative and quantitative changes in health care. Some of the
qualitative changes are good, some not-so-good and yet others definitely bad. The
health situation in the country continues to be bad. Preventable deaths continue,
whether it be infants, children or adults, in their millions. India is worst among
the various regions in the world (except for sub-Saharan Africa) if we consider the
disease burden per 1000 population.
The health systems have a number of
problems : misallocation of funds, inequity and inefficiency.
Among the present and emerging problems are
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the widening gap in health care between the ‘haves and the have-nots’;
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the increasing costs of health care services;
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the greater dependence on costly, sophisticated and unnecessary tests;
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the weakening of the doctor – patient relationships;
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commercialisation of health care services; and
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non-adherence to the principles of medical ethics in the practice of medicine.
2. THE MIX IN THE HEALTH SECTOR
We have a mix of Public (Government), Voluntary (not-for-profit) and Private
(for-profit) sectors in Health Care. The Public Sector has been the most dominant,
though it is not the largest. The Voluntary Sector, though smaller, is significant.
It has been a pacesetter in many areas. The Private Sector has always been very
large in providing medical care. It has a very wide spectrum, starting from the
individual general practitioner, the small nursing homes, to the large corporate
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hospitals. In recent times, with the advent of the large corporate hospitals, the
Private Sector has assumed greater visibility.
Privatization
The Governments, both at the centre and the states, are supportive of privatization.
Such privatization is actively encouraged by the World Bank, International
Monetory Fund and other similar powerful organizations. The Governments have
encouraged privatization actively and passively by giving land (free or at a
nominal price), allowing duty free import of equipment or handing over hospital
buildings or other health care facilities to private agencies. The National Health
Policy – 2002 welcomes the participation of the private sector. Private sector has
also grown because of default by the public sector.
Number of hospital beds
Is there a need for more hospitals and hospital beds; or, is there an over supply of
beds? If we consider the whole of India, we need many more hospital beds. India
has the least proportion of hospital beds per 1000 population among all the
regions in the world. But there is great variation between the states. The Bhore
Committee (1946) had suggested a long term plan of more than 5 beds per 1000
population. Later committees suggested a reduced target, mainly because the
country could not sustain such numbers. It is time that we had a realistic estimate
of the need – numbers, location and types of hospitals and inpatient beds.
Type of care
We need comprehensive health care. The Public and Voluntary sectors have been
providing, to a greater or lesser extent, wholistic care – promotive, preventive and
curative care (very little of rehabilitative care). The emphasis of the private sector
has always been on curative medical care, without providing promotive,
preventive or rehabilitative care.
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The Public sector is involved in primary, secondary and tertiary care. The stated
policy has been to give emphasis to primary health care and public health. The
Voluntary sector is mainly involved in primary and secondary care. The private
sector is involved in primary care (general practitioners), secondary care (the
nursing homes) and the private corporate hospitals mainly in tertiary care.
Cost of care
The Public sector is expected to provide free care, especially to those below the
poverty line, meeting the expenses from the general taxes paid by the people.
With the introduction of user fees and other charges, some payment is necessary.
There are also hidden charges, unofficial payment demanded by health personnel
to get things done. People (even the poor) are asked to buy medicines and other
medical accessories. Even to see the newborn by the mother, money has to be
paid (in some government maternity homes and hospitals).
The Voluntary sector works usually on the no-loss-no-gain basis, meeting all the
operational expenses from the charges levied.
This is achieved by having
different levels of charges for the affluent, middle class and the poor. The poor
are given free or concessional care, meeting the deficits by charging the rich
higher than the standard rates. Some institutions have poor funds so as to enable
them to give free care to the indigent. The private-for-profit sector is motivated
by profit. Their charges are high so as to maximise profit. The services are
mostly not accessible or affordable to the poor. Some institutions do look after a
few poor patients and may give some concessions.
Some questions
A number of questions arise:
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How do the three sectors function together? Is it competition, collaboration or
co-existence?
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Can the three sectors collaborate in ensuring comprehensive health care for all
– available, accessible and affordable?
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Does the existence of the three sectors lead to additional resources in health
care?
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Does one sector pull resources (especially human) from the other?
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Is there unhealthy competition (like providing costly, sophisticated equipment
and advertising the same) increasing the cost of care?
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Does each sector learn from the other to improve quality of care and
management of the institution?
3. ADVANCES IN MEDICAL TECHNOLOGY
The greatest change in health care services has been the increasing use of newer
diagnostic and therapeutic technologies. Imaging systems like Ultrasound, CT
scanning and Magnetic Resonance Imaging are being used routinely.
Laporoscopes enable small hole surgeries.
Cardiac surgeries – by-pass,
angioplasty, correction of congenital defects and other open and closed heart
operations – have become very common.
Kidney transplantation is fairly
common, mainly with kidneys obtained from unrelated, live ‘donors’, which is
giving rise to many ethical problems. Other transplants include cornea, skin, liver,
heart, lungs and others.
In the case of unpaired organs like heart, it has
necessarily to be from cadavers. Cadaveric transplantation in a big way is yet to
take off.
Information Technology
The immediate advance will be in Health Information Technology.
Medical
informatics can be used to
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improve clinical practice;
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schedule resources (personnel, money, materials, time) more efficiently;
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improve patient records and quicker access to records.
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Tele medicine can be an enabling technology to facilitate transfer of information.
The idea is to bring service to the point of needs without moving anyone: patient
to doctor; doctor to patient; doctor to doctor and doctor to society. E-medicine,
faxes, and telephonic consultations link patients with health care providers. They
promise to improve access to health care services in rural areas with shortages of
doctors and health care institutions. Issues like cost, patient consent and licensing
will have to be addressed before tele medicine becomes an accepted mode of
delivery of services.
Genetics
Among the emerging technologies are genetics and genetic engineering. With the
determination of the human genome and the identification of the genes
responsible for the production of various proteins, genetic defects can be
countered. With the research on stem cells, organs and tissues can be grown.
These can be transplanted to replace defective or damaged organs and tissues or to
enhance the functioning of existing organs and systems. Such developments can
be misused for the discredited eugenics. Cloning technologies may be used and
embryos obtained through in-vitro fertilisation. By embryo transfer, foetus may
be grown for the sole purpose of using the cells for transplantation, destroying the
foetus.
Experimental research is going on where organs and tissues of other species may
be used to replace the damaged organ or to augment its function The pig seems to
be a prime candidate for donating organ (eg., heart). There are many unresolved
and unknown problems.
Certain viruses may be released which may be
pathogenic to the human and then spread rapidly among the people.
Newer technologies are coming all the time. Many of them are discarded soon
after, because they are useless or even harmful. There is need for assessing health
care technologies before they are used. Utilization reviews, quality assurance and
medical audits are needed. Clinical, scientific and economic appraisals must be
carried out of all new medical technologies, including the newer procedures.
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4. INEQUITIES IN HEALTH
“Everyone should have access to basic health care independent of their ability to
pay” – We hear this rhetoric from the politicians and policy makers all the time.
Yet, the facts are different. There are major gaps between the ‘haves’ and the
‘have-nots’. The poor die earlier; their life expectancy is less. They suffer more
from disease and disability. We need greater equity in health.
Equity in health can be measured using different parameters:
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Access to health care services
Access to basic health care is unequal. The poor have less access to simple,
cost-effective services. There are economic, social and cultural barriers. They
have often to travel more, because the health care facilities are situated further
away and incur relatively more for travel expenses. The daily wage earners
have to forego their wages.
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Utilisation of services
Individuals, families and communities belonging to the lower socio-economic
groups are less knowledgeable about the services available and hence, make
less use of them. Individuals in the higher income groups make more visits to
the health care providers than those in the lower income groups.
The
introduction of user fees has worsened the situation. The poor postpone or do
away with the visits, even where necessary. When they do seek health care,
the disease may be in an advanced stage.
Health outcomes
Health outcomes are the result of a combination of various inputs besides
health services. These include education, food and nutrition, water supply and
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sanitation, housing, exercise, life styles, occupation and income. The ideal
measure of equity in health is health outcome, though it is difficult to measure
the contribution of health services to health outcome.
Individuals fall ill differently based on their socio economic status and the
level of development of the community. Individuals even with similar health
problems fare differently depending on their social status and income. The
poor are less likely to acknowledge that they are sick; when sickness is finally
acknowledged (so sick that they cannot work), the poor are less likely to use
the available services. Even if the services themselves are free, seeking care
and getting it involve other costs, eg., transportation and time lost from work
for self and persons accompanying. There are also hidden costs, such as
gratifying the health professionals and workers.
There is inequitable distribution of public resources for health. The chief
agents act to maximise individual utility rather than social welfare. Politicians
seek to maximise capture of publicly financed services. They and the officials
stand to gain from projects for large hospitals. These are highly visible and
popular, often seen as evidence of government commitment to medical care.
Health professionals and their associations may be a major source of
resistance to change, which is likely to benefit the poor.
When smaller
peripheral facilities are established, the doctors, nurses and others will be
redeployed there and they often resent it. Specialists clamour for costly,
sophisticated equipment and other facilities, which will not be available in the
smaller health centres. They become frustrated and do not wish to work in
such centres.
Equity requires a re-distribution of the allocations. It also requires information
being made available to all people on the degree and distribution of the health
facilities. If equality in health outcome, utilization of health facilities and
access to them are to be ensured, we need higher public spending on the poor
per person than on the rich.
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Equity calls for greater public spending on healthcare. The poor depend on the
public sector. The Alma Ata Declaration (1978) had called for increased
government spending on health. India is a signatory to it. But under the
influence of World Bank
and International Monitory Fund (Structural
Adjustment Programmes), India was forced to reduce allocations to the Public
Sector (so as to repay the debt) and to privatize the services. Cost recovery
schemes often placed the health services out of reach of the poor families.
This tendency is likely to increase and we may find increases in child
mortality and diseases like tuberculosis.
5. ESCALATING EXPENSES
The cost of medical / health care is increasing all the time. Health care services
are being driven beyond the capacity of a large percentage of the population. The
poor become poorer because of the medical bills.
The Cost of Drugs
The cost of drugs has been going up relentlessly. Price Control Orders are cutting
down the number of drugs (bulk and formulations) under price control, giving free
hand to the manufacturers to increase their profits.
The operation of the Drugs Prices Control Order by the National Pharmaceutical
Pricing Authority is being sabotaged through a large number of litigations. The
Government is considering the establishment of an Apellate Tribunal to hear all
such cases. The proposed centralised, autonomous tribunal would arbitrate on all
pricing – related issues. All cases on drug pricing in the various High Courts
would be transferred to the tribunal. Appeals from the decision of the tribunal
will be with the Supreme Court (The Economic Times, 21.7.2002).
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The Patent Act
With India signing the GATT agreement and the World Trade Organisation
pronouncing judgments in favour of the large multinationals, market economy has
taken over. This affects the poor especially.
“Market economy cannot solve the problem of poverty in the world”
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Butros Butros Gali, Secretary General, United Nations,
1995.
Market economy aggravates poverty and poverty affects health.
Economic
liberalization and free market economy have increased the prices of drugs and the
equipments, affecting the cost of medical and health care.
Trade Related Intellectual Property Rights (TRIPS) brought product patents. This
will be fully effective in India in less than three year’s time. It allows product
patent exclusive rights for 20 years from the date of filing the patent application.
The Indian Patent Act, 1970 recognized only process patent. India could produce
the essential drugs within 4 or 5 years of a product becoming available elsewhere,
at a cost which was only a fraction of the cost in the affluent countries. Now it
will take 20 years, by which time there will be newer and more effective drugs for
the same disease and the cycle will be repeated. The cost of the patented drug will
be kept enormously high as was seen in the case of anti-retroviral drugs against
Human Immunodeficiency Virus causing AIDS. The patented drugs, produced by
the transnational drug companies in USA, UK, etc., cost more than 10 times the
cost of the same drugs produced by companies in India.
6. COMMERCIALISATION OF HEALTH CARE
Health care is changing from a humane service to a commercial enterprise. It
affects all aspects of health care.
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Health Professionals
Unnecessary procedures are being carried out increasingly, the motive being to
make more money. An earlier example of such unnecessary procedures was
‘transillectomy’. Later, ‘appendicectomy’ became popular. Still later, it became
‘caesarian section’.
While there are many genuine indications for caesarian
section, far more caesarian sections are done than necessary. In some hospitals,
the rate of caesarian section has become even 40% of all deliviries. The number
of ‘hysterectomies’ has shown a quantum jump.
Far too many diagnostic tests (especially the costly, sophisticated ones) are being
done, though not warranted by the need. These are sometimes ‘justified’ by
saying that the Consumer Protection Act has made it necessary to avoid claims for
damages. The doctors want to ‘protect’ themselves. They practice what is called
‘defensive medicine’.
There is irrational prescribing of costly drugs because of kickbacks.
Pharmaceutical firms give gifts and perks for prescribing them.
These may
include costly household goods or fully paid holidays in exotic regions.
Unnecessary referrals are made. When a patient is referred, the referring doctor
may get a cut. The Medical Council of India is against such ‘cut practices’ but the
practice goes on merrily.
Organ transplantation (the live, unrelated, kidney ‘donation’ and transplant) has
become a big racket, with the spoils being shared between the doctor, the hospital
and the agent; the poor ‘donor’ also gets a share. The World Medical Association,
2000, states : “Payment for organs and tissues for transplantation should be
prohibited. A financial incentive compromises the voluntariness of the choice and
the altruistic basis for organ and tissue donation …. Organs suspected to have
been obtained through commercial transactions should not be accepted for
transplantation”. The doctors involved almost always know that the so-called
‘donation’ has been made for financial considerations, exploiting the poor but,
prefer to close their eyes and shut their ears for financial gain. Another racket
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which has been making headlines recently because of the Supreme Court
decisions is ‘sex determination and selective termination of pregnancy”, if it is a
female foetus. A lot of noise has been made but the effect is nil. “The dogs bark
but the caravan moves on”.
Pharmaceutical industries
There is unethical promotion of drugs, violating the WHO guidelines. Unwanted,
unnecessary and ‘me-too’ drugs are produced and marketed using questionable
procedures. Substandard drugs are marketed, whether the firms are the large
multinationals or the small manufacturers. Brand drugs (high cost) are promoted
when equally potent and much less costly generic drugs will do. Immunization
procedures are promoted even when they are not necessary effective or affordable.
Equipments
Unnecessary and costly equipments of doubtful value are purchased
(commissions?). Unnecessary tests are prescribed and carried out so as to recover
the cost and make a profit. In the public sector, they often lie idle because there is
no one to operate them or the needed repairs cannot (will not) be carried out.
Education of health professionals
Colleges for the education of health professionals (doctors, nurses, pharmacists,
etc.) have sprung up in the private sector, exploiting the demand for ‘qualified’
persons. Recently, there was an advertisement in ‘Deccan Herald, Bangalore’,
calling for the sale of a medical college. These colleges are substandard, without
the necessary infrastructure.
They do not have the required teaching staff,
‘borrowing’ the staff from neighboring colleges at the time of inspection by the
councils. Substandard students get admitted paying enormous fees. Very often
such students ‘pass’ the examinations, resorting to ‘payments’ to the examiners.
Some examiners take advantage of the situation and demand ‘payment’ from all
students : good students ‘not to fail’ and bad students ‘to pass’. The demand for
degrees, especially in nursing, is mainly for ‘export’.
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Hospitals
The Corporate Sector hospitals invest heavily in the ‘health care industry’. These
‘five star’ hospitals invest in the latest (often unproved)high cost technology.
They want quick returns and advertise the availability of these equipments. All
methods are adopted to get enough ‘clients’.
Diagnostic Centres
More and more high technology diagnostic centres are coming up in the cities and
larger towns. To make profits on the investments, these centres need large loads
of work. To attract more requests for the costly tests, ‘incentives’ are given to
doctors who ask for them.
7. DETERIORATING DOCTOR–PATIENT RELATIONSHIPS
One of the cardinal requirements of health care is good patient-doctor relationship.
The patient requests for help, placing trust in the doctor. The doctor has to
respond both as a healer and as professional,
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being courteous, compassionate and committed to the patient; and
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using the medical knowledge, skills and attitude to the best of his/her ability
and in the best interests of the patient.
Sushruta Samhita says:
“The patient may doubt his relatives, his sons and even his parents, but he has full
faith in the physician. He gives himself up in the doctor’s hand and has no
misgivings about him. Therefore, it is the physician’s duty to look after him as his
own son”.
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The relationship is one of trust.
There has been an erosion of trust and commitment. This is likely to continue and
even increase. One of the requirements for good patient-doctor relationship is to
inform as skillfully and accurately as possible about the patient’s condition, the
alternatives available, their benefits and risks and the best possible approach. The
patient then gives the informed consent to the proposed procedure.
The
autonomy of the patient is respected.
With the advent of more and more sophisticated technology, there is the tendency
to place greater reliance on the results of the tests and less on the perceptions of
the patient. There is less communication between the doctor and the patient.
There is deterioration in their relationships. The relationships become impersonal.
What should be the ideal doctor-patient relationship? There is the possibility of
conflict between ‘patient’s autonomy’ and doctor’s view of what is ‘best for the
health of the patient’. There can be conflict between the ‘values’ held by the
patient and those of the doctor. The doctor must appreciate the values of the
patient, provide factual information, help the patient to make up his / her decision
and implement the informed choice.
It is not enough to have good patient-doctor relationships. The doctor must
cultivate good relationships with the members of the family of the patient and the
community, while preserving confidentiality.
8. FORGETTING MEDICAL ETHICS
Doctors are bound to observe the principles of medical ethics in their practice.
The cardinal principles of Medical Ethics are
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Beneficence (doing good);
•
Non-maleficence (doing no harm)
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Justice (social / distributive);
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Autonomy (as opposed to paternalism).
Codes of Conduct
There have been many codes of conduct from ancient times. In India, these
included atreya anushasana, Charaka Samhita and Sushruta Samhita. The Oath
of Hippocrates (Greek) is followed by practitioners of Western Medicine. Doctors
in India take this oath (in a modified form) at the time of graduation and
admission to the medical profession. There is an International Code of Medical
Ethics (1983).
The Medical Council of India had formulated a Code of Ethics to be followed by
the practitioners of Medicine in India. This has now been revised and issued as
the Indian Medical Council (Professional Conduct, Etiquette and Ethics)
Regulations, 2002. They deal with
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duties and responsibilities of the physician in general;
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duties of physicians to their patients;
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duties of physician in consultation;
•
responsibilities of physicians to each other; and
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duties of physicians to the public and to the paramedical professions.
It gives also what are unethical acts, misconduct and punishment and disciplinary
action.
Medical profession used to be considered a noble profession. But today, the
profession is losing some of the respect and regards that it had enjoyed earlier.
There are serious criticisms of the medical profession : its lack of accountability,
its structure and organisation, its undue dependence on newer and unnecessary
technology and its failure to address important issues in health.
There are
numerous litigations of malpractice, negligence and incompetence. Medicine in
India is regarded as
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being overly protective of its rights, status and income;
•
being guilty of ignoring the wider social problems; and
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failing to regulate itself effectively.
It is necessary to take immediate corrective action individually and collectively to
stop the downward slide for the benefit of all.
The Future
The trend today is for more privatization and commercialization and for increase
in the cost of health care. This trend will continue unabated unless active steps are
taken to reverse it. There are positive signs that a change may take place. There
are growing groups of people aware of the situation; they are protesting against
commercialization locally, nationally and globally. There are national and
international movements asking for low-cost medical care and generic medicine.
There is some disenchantment with the costly, sophisticated investigation and
demand for more humane medical care with better doctor-patient relationship. The
Rajiv Gandhi University of Health Sciences, Karnataka has made the teaching and
learning of Medical Ethics as an integral part of its curriculum for the medical
students. Other Universities may follow suit. We can then expect Medical Practice
to be more ethical, more people oriented and less commercial. There is rethinking
about the role of the World Trade Organisation, which can change ‘liberalisation’
(meaning market economy favoring the rich nations). All these changes will need
the Political Will. That political will come about if there is a movement of all
concerned people.
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