Regulations, Laws and Ethics in Healthcare Delivery in India
Dr. Kamal Mahawar is Consultant General and Bariatric Surgeon with Sunderland Royal Hospital in the United Kingdom. He is also an Associate Clinical Lecturer with Newcastle University and editor of renowned scientific journals. His recent book ‘The Ethical Doctor’ published by Harper Collins India examines some of the serious issues affecting Indian healthcare.
Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem.
Indian society is going through a catharsis. In an increasingly interactive but ever more disintegrated world, Indians are finally finding both the confidence and the desire to transform their own society. A country of 1.3 billion people is no longer prepared to accept being an “also ran”. In this process of churning, undeniably, there will be much pain but from this one hopes, will emerge an India – confident, strong, and sure.
There is a lot wrong with contemporary Indian society – it’s thinking, it’s structure, it’s systems but we still have a chance. Each one of us alive today will not be here in say just less than 100 years time. Almost every single house in the country will become inhabitable in not too distant a future, and our cities will almost completely have to be rebuilt. We just need to ensure that the “new” that replaces the “old” is robust and before you know India would be transformed. I sincerely believe that with appropriate corrective action, we can resurrect almost every aspect of the Indian society – yes it’s thinking, the structures, and even the systems.
This corrective action, however, will only become possible if we come out of our current situation where failure has led to arrogance rather than introspection. We will have to start by admitting freely and openly what is wrong with our society and then engage in a collective discourse to fix it. We need to raise both the level and the intellectual quality of our public discussion and move forward slowly – a step at a time – but decisively.
Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. The task at hand is enormous.
Healthcare industry is heavily dependent upon human resources. You can’t look after patient without doctors, nurses, technicians, etc. and yet little thinking has gone into ensuring an adequate work-force for the future that we can retain to work in the country. The current situation is that we are creating doctors and nurses but without the adequate hospitals and clinics for them to work in. The government keeps saying doctors and nurses don’t want to work in rural India but without understanding that doctors and nurses need adequate facilities, diagnostics, and other supporting services to deliver healthcare. Doctors and nurses need decent houses, schools for their children and facilities for a productive and entertaining social life. Given the fact that this is unlikely to change anytime soon in rural India, we will need to provide incentives for people to work in the villages – the same sort of thing that can force a doctor or a nurse to go and work in a small town in Saudi Arabia can also take them to a village in their own country. Our planners simply need to wake up to this reality. If a doctor or a nurse sees that he’ll save for four years by working for a year in a village, he is likely to drag himself there and also ensure he works hard to keep his patients and employers happy. The current situation where nobody wants the job in the first place does not leave the government with any levers when those in it don’t perform or simply don’t turn up! Adequate salary and tax incentives can go a long way in helping retain our homegrown talent and will ultimately pay back for itself by ensuring a healthier society. Health, after all it used to be said, is wealth.
The Role of the Government
In modern societies, we have left it to the governments to set the appropriate structures upon which we can all build our individual lives. If the structure is robust, our lives can indeed be very fulfilling but if it is not, the whole system can degenerate into chaos. The policy has failed Indian healthcare at every step and exploited by the very people entrusted to protect and develop it. Doctors continue to be educated and trained in a system that rarely keeps pace with the changing needs of the patients and the scientific developments. Underfunded medical colleges continue to treat the impoverished in shabbiest of the conditions and produce little in the name of research and scientific
output. They struggle to recruit world-class faculty while those who take up these jobs find they can neither deliver world-class care nor engage in academics or research because of the lack of funding and bureaucratic controls. Our corporates happily donate millions of dollars to foreign institutes as they have well-established mechanisms for publicity that our institutions have failed to establish. And while our educational institutions and hospitals are crumbling due to lack of resources, our temples are one of the wealthiest in the world. There is much for us all to reflect over in the contemporary Indian society.
At the same time, it cannot be denied that healthcare is fundamentally the doctors’ responsibility in any society. If any of the other stakeholders’ are falling short, it is up to us to make noise and ensure we can deliver quality healthcare to the people. However, Indian healthcare is remarkably short in this area too. A large number of doctors, let down by the system, have become so cynical that greed and self-aggrandisement have taken over empathy and ethics. The profession has got infested with one corrupt practice after the other and the doctors have simply chosen to look the other way. Yet, they complained bitterly when medical services were brought under the purview of the consumer courts. I agree that involving courts was not the right thing to do but what options did the doctors leave for the patients when the regulator, the Medical Council of India (comprising entirely of doctors), does not have an effective patient complaint cell or even a register of all qualified doctors. It is true that the desire of the medical profession in India to protect each other is much stronger than their will to protect patients. And while the rot was setting in, the so-called leaders of the profession were building their own hospitals and nursing home. Isn’t it amazing that not a single leader from the profession has spoken against the widespread lack of healthcare provision in the country for the poor or the ethical abyss that the profession has sunk into? It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. If you don’t believe me, just think how many of hundreds of medical societies in the country come out with anything useful for the people. Where is the desire to develop the local evidence base to guide local care? Where are the local guidelines for common clinical conditions that can be used by doctors and nurses working in remote towns and villages? Despite this, hundreds of conferences are organised annually at considerable expense and much fanfare where the emphasis is on reciprocating lectures and chairmanship rather than any real scientific data sharing. There will no doubt be islands of excellence in this vast sea of greed and corruption but I hope I have been able to give you a general idea of the state of the affairs. Many of these problems are not simply confined to India either.
The Private Sector
The private sector rose to fill in the vacuum left by the state and it is a fact that without private healthcare, large sections of our communities will have nowhere to go. But once again, the private sector has been allowed to mushroom without any attempt to match demand to supply. This has led to a situation where they are killing and pulling each other down into a moral quagmire with over competition in urban areas while vast sections of rural parts of the country are left un-served. Private nursing homes, diagnostic facilities, and hospitals are functioning without a regulatory overseeing mechanism and poor patients have no alternative, as the state hospitals are not fit for human treatment.
Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem. We need reform across the board. We need to reform our state primary health care provisions, our medical colleges and how we fund them, medical education and postgraduate training, continued medical education, regulation of the profession and the hospitals, mechanisms for patients to voice complaints, planning to distribute provisions evenly, and systems for accountability from all. And even if we did all this, there will be yet more left to do.