A few years ago, I was participating in a discussion on the future of healthcare at a leading institute of health management. I have heard several panelists affirm that health and public health should absorb and implement practices that enhance the efficiency of business management. I agreed, but only partially. I said “The mantra of business management is efficiency and profit, while the mantra of health and public health management should be efficiency and equity.” While underlining this important difference in the goals of these two practice disciplines, I should have added the analogy as well as ethics. I politely assumed that health care management would ideally be tied to ethics, even if it pursued efficiency and profit.
However, that reserve was breached a few months ago by angry complaints from a leading doctor at a large private hospital in Hyderabad. He complained to me that the way private hospitals are being run ruthlessly by management graduates who have no medical background. He said he lacked empathy and that his sole aim was to maximize profits for investors who owned the hospital. The situation is deteriorating, he said, as foreign investors have gained control over the established Indian hospitals. Their representatives were squeezing doctors to generate more and more revenue, often through unnecessary tests and procedures as well as over-billing. These complaints were nothing new, but hearing this from a prominent doctor at a private hospital, who felt oppressed and revolted by unethical practices, showed the extent to which mercenary management had derailed value-based medical practice. was taken off.
I was reminded of this when I received a WhatsApp message for an anonymous post by “an Indian doctor”. The subject of that post was the extreme pain and critical condemnation of the state of private hospital management by non-medical MBAs. A sample of the thoughts expressed (from minor excerpts from that scathing critique): “No manager knew the sinking feeling of looking into the eyes of a costly patient and telling him that you had to bring in more money to live on.” He complained that, apart from torturing patients, some hospitals were also charging doctors for their car parking slots!
The post also listed other evils of commercial private healthcare, whose practices were being shaped by non-medical managers: doctors being criticized for partial pay waivers to poor patients, threats from their pay cuts. was given; Bullying at the level of revenue brought in through trials and procedures, forcibly determined and even more so when unnecessary, and with slyly higher billing. A fervent appeal of that post was that doctors should gain control of hospital administration from non-medical MBAs.
I forwarded that post to the senior private doctor in Hyderabad, who had earlier expressed his feelings to me. His response was scathing – “We cannot exonerate the doctors who became entrepreneurs and commercialized everywhere.” He argued that many hospitals were started by reputed doctors who provided high quality care. However, as they wanted to attract more investment for expansion, they let the financiers take control. The value has declined as the valuations unfolded. Some medical entrepreneurs cashed in on the high market value and sold them to international and Indian traders. The former had no emotional or moral commitment to Indian patients, while the latter saw the control of hospitals as a route to higher revenue opportunity and social and political influence. The interests of the patient no longer mattered.
There are two broad segments of the private sector that provide healthcare. An individual is the unorganized private segment of healthcare providers (both qualified and unqualified). In the organized healthcare sector, we have for-profit and non-profit making sectors. Many of the first two volumes have done well in service provision and respected ethical norms. It is the third section that denigrates private healthcare. The worry at the moment is that many tier II institutions are moving to tier III.
I did my undergraduate and postgraduate medical education before large corporate hospitals emerged. The ethos of medical practice at that time was markedly different. With the advent of corporate hospitals, there was improved access to quality health care for those who could afford to pay. The poor could not afford this kind of care, while the middle class who had access to high-end private care faced severe financial stress.
In recent decades, governments have also been buying services from the organized private sector through publicly funded health insurance schemes. The government also provides several concessions to the private sector for setting up or expanding their facilities – land, water, electricity, customs duties etc. There is both a need and opportunity for the central and state governments to exercise their regulatory powers to ensure ethical and cost-effectiveness. Adaptation of practices by the private sector.
Overuse of health care, including unreasonably driven demand, has also been a feature of health systems in the US. A recent study of 676 US health care systems reported that those who were using healthcare more, had more beds, had fewer primary care physicians, had more physician practice groups, had more investor ownership. were more likely to occur and less likely to involve a major teaching hospital. Of these, investor ownership and the paucity of primary care physicians are factors particularly relevant to India.
Unfortunately, public sector healthcare providers are also operating like private healthcare. Many doctors who are formally employed in government hospitals also work in private hospitals, often hindering their clinical and teaching work in public hospitals. Until the early 1990s, doctors working in government hospitals in many states had private practice in the evenings after their regular working hours. He never neglected patients or students during his day to day commitment to government health institutions.
The growth of corporate hospitals changed that. Once government doctors began moonlighting in private hospitals during their working day, the focus was on patients as well as bedside clinical teaching, as little time was spent in the public hospital, which was their place of duty. was. It is time we stop our government doctors from private practice and pay them well. Having trained and working at AIIMS, Delhi, I know the value that dedicated time commitment brings to the quality of patient care. This would not have been possible had AIIMS allowed its doctors to do part time private practice.
The voluntary sector in India can proudly claim to have many excellent health institutions. Even though some of them are labeled as private, they have cross-subsidized care provided to the poor and have excellent ethical standards. However, these institutions are not geographically well distributed and do not have the financial resources to rapidly expand their reach and expand their services. Even institutions that have medical colleges attached to hospitals or have credible postgraduate training programs practice ethical, evidence-based care. Usually, their hospitals are not run by non-medical MBAs. Their management teams are led by doctors.
India’s mixed health system has evolved by default and not by design. We cannot turn the clock back. We need to make the best use of all our healthcare providers to provide optimum healthcare, which avoids exploitation of vulnerable patients. To improve access, affordability and quality of healthcare in India, we need to make the public sector more accountable, the private sector more responsible and the voluntary sector more resourceful.
(Prof. K. Srinath Reddy, a Cardiologist and Epidemiologist, President of the Public Health Foundation of India (PHFI). Views expressed are personal)