Challenge before the National Health Policy: Rebuilding trust between Patients and the Healthcare system

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In the months of February and March a couple of incidents took place in hospitals across the country that need close consideration. In Dhule, Maharashtra an Orthopaedic Surgeon Dr Rohan Mhamunkar was beaten up severely by some patients relatives for not attending their patient quickly enough. Then in Mumbai Sion Hospital a junior doctor as beaten up. This was followed by news from Aurangabad that a similar incident had happened. The news about this series of attacks on doctors led the doctors association in Maharashtra to strike calling for safe work environment. The Maharashtra Association of Resident Doctors (MARD) claimed that over 50 such cases had taken place in the last one year. The Bombay High Court did not look favorably at this strike and said that is was a matter of shame “if doctors go on strike like factory men”. It further advised that if, “they want to continue their strike then they should stay 100 feet away from hospitals”. Far away from Dhule in Kolkata anger against private hospitals for charging exorbitant fees spiraled into a patient doctor face off. Dr Suneep Banerjee an intervention cardiologist was sued for negligence by patients’ relatives when a patient on whom he had conducted angioplasty died after amputation for gangrene of the leg. Then in Chittaranjan Medical College Hospital the relatives of a patient beat up the doctors on duty when their patient died during treatment.

In Maharashtra the situation has eased somewhat, but not before doctors in other cities and states started protesting and the Government relented, agreeing to post security guards. In West Bengal, the Government has tried to resolve the public anger against hospitals by enacting the Clinical Establishment (Registration, Regulation and Transparency) Bill, 2017. This bill has further upset the doctors in the state who feel that this puts all their clinical decisions and actions under unwarranted scrutiny and many doctors feel that this will not only open a flood gate of cases against them but also incite violence.

The Medical Council mechanism is dysfunctional with the Indian Medical Council being suspended by the Supreme Court for not fulfilling functions. There are no effective regulations around clinical standards and quality of care.

These incidents draw attention to the fact that the relationship between doctors and hospitals and patients and agencies of the state is tense. Services at both public and private hospitals are being seen with suspicion and the trust that patients and society at large had with respect to doctors has been severely eroded. It is important to understand the reasons behind this severe breakdown in trust regarding one of the most hallowed institutions and professions of society.

There are four key players in this relationship – the doctors and hospitals are in one corner and the patients are on the opposite corner. Somewhere in between is the state, unsure about its role – arbiter or supporter of one side or the other. To understand this relationship one needs to go back thirty five years. The first round of liberalization gave an impetus to the private medical industry. While India’s healthcare has always been served by a large ‘private sector’, liberalization meant that the unorganized sector of small nursing homes have over time been replaced by large corporate entities. Earlier most of the well-known and ‘star’ specialists would be associated with a government medical college and at the same time have their practice. Over time the government run medical colleges lost these consultants and new consultants were no longer joining the government one’s. Side by side large number private medical colleges emerged all across the country – and admission to these was no longer by merit alone but with large ‘capitation’ fees as well. Now healthcare was no longer a public good but and industry and medical education was no longer for a social purpose but only a means to a lucrative profession.

As India’s health care industry boomed it became attractive to patients from neighbouring countries as well as those in far-off Africa and the medical tourism industry was established. At the same time the Government health care system comprising of sub-divisional hospitals, district hospitals and medical colleges creaked under an ever increasing patient load. Doctors in these hospitals often were double timing – concurrently see patients in their private chamber as well as in the government hospital. A network of associated medial service providers grey up around hospitals – laboratories, X-ray, ultrasound and CT clinics mushroomed around hospitals, providing incentives to doctors to send patients their way. It was not surprising that some prescription audit have shown that patients often had a long list of drugs and tests many of which were not completely necessary.

In the 2000s economic studies of healthcare in the country started revealing a pathetic reality. India had among the lowest public investments in health anywhere in the world. It was not surprising therefore that hospitalization was among the leading causes of impoverishment. While there has been a call for increasing public investment in health the growth of the health budget has been very slow. However healthcare contributes over 5% to the GDP. This means that most of the healthcare cost is borne by the patient. And in India this is direct payment at the point of care, because few Indian’s have health insurance and the nature of health insurance too is not comprehensive. So while the healthcare industry has grown, it has done so through rising medical bills – which go to pay the hospital, the ancillary medical services which are often part of the hospital infrastructure, and of course a new breed of doctors many of whom have been trained privately. Even doctors who have received state sponsored training rarely seek public service as medicine is increasingly seen as a high paying profession, and corporate hospitals are the only place where they can ply their expertise.

Besides high payment, another illness that plagues the Indian healthcare system is a complete lack of accountability. The Medical Council mechanism is dysfunctional with the Indian Medical Council being suspended by the Supreme Court for not fulfilling functions. There are no effective regulations around clinical standards and quality of care. The recently enacted Clinical Establishment Act has been adopted by a small handful of states and even there the rules remain to be framed. Thus a privatized, highly expensive but unregulated health care sector was a disaster waiting to happen.

While these changes have taken place in hospitals, doctors and in public policy making around healthcare, the patient profile in India has also undergone rapid changes. Exposed to the market and new information technology, they are no longer docile. They have more aspirations, but they also face the crippling cost of health care. They expect results as they pay. Patients know doctors take ‘cuts’ and are now impatient. While policy makers have been hesitant to raise the health budget, the politicians current stands against hospitals and doctors in West Bengal and Maharashtra shows their clear empathy with their electorate. They are quick to take action against the erring doctor and hospital without realizing that this is also the result of decades of policy inaction in the health sector.

It is in this reality that the National Health Policy 2017 has been announced. It has very ambitious goals. It promises assured health services for all and to raise the health budget by nearly twice in the next eight years. It promises to strengthen public hospitals and to align the growth of the private sector to public health goals. These are extremely welcome goals. However like all Indian public policies, the proof of the pudding will be in the way it is implemented. Without clearly finding ways to reduce costs of health care, strengthen regulatory and accountability mechanisms and bringing doctors back to serve the people with care and respect, it will be difficult to build trust between the health care system and the public.