The private health sector in India
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7526.1157 (Published 17 November 2005) Cite this as: BMJ 2005;331:1157
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I congratulate Amit Sen Gupta and Samiran Nundy for bringing into focus the ills of the healthcare scenario in India, today. There is no denying the fact that independent India immediately after 1947 had an effective public health sector which provided adequate service to the poorer sections of society as well as the middle class. With the passage of time this sector has gradually undergone a steady deterioration despite large budgets and liberal contributions from foreign countries and international agencies.
The setting up of postgraduate institutes by Acts of Parliament which have complete autonomy and highly qualified faculty members recruited from the best available in the world as well as ample funds have not improved the plight of the common man. The work load of the doctors and incessant interference by politicians and bureaucrats has led to their goals of providing high quality health care to the poor, good medical training suitable to our country’s needs and research into Indian diseases being missed. The weaker sections of society are still no better off. This is also because with the passage of time the initial idealism has flagged, the targets and agendas have become diluted and the best professional talent in the institutes have frequently left to work abroad or join the private sector, mainly for fiscal reasons. Today the public sector and government have abandoned their leadership roles in health care as well as in the management of major railway accidents and other disasters.
The infusion of mammoth funds into the public sector today, will not make an iota of difference. There is a total lack of accountability compounded by inadequate monitoring by the government. This lack of governance has led to suspect professional practices such as large scale pilfering of consumable items and the misappropriation of funds meant to provide service to the poor and the needy. This is the cancer which is eating into the vitals of the public health sector scenario. Only the will of the government agencies to stop these rapacious and marauding practices can prevent irretrievable damage.
Corporate hospitals structured by industrial houses with their main motive of profit- making, who make little or no contribution to the health care of the weaker sections of society must not be allowed to secure government approval and support. Their functioning and how they came into existence has been outlined in great detail by Justice Qureshi whose voluminous report is gathering dust in the government archives.
These corporate hospitals are not at all interested in academic medicine which provides the medical profession the wellspring to thrive, study, carry out research, discourse, evaluate, treat, learn and improve. Academic medicine which contributes to the overall progress in medicine and bringing down health care costs is totally ignored.
On one major issue I completely disagree with the authors. Medical tourism should be encouraged and promoted. Community hospitals which are managed by doctors or even Trust hospitals in which doctors have a say are providing quality health care either free or at a highly subsidized price to the weaker sections of the society. They also service the more affluent section of society with competence and elan. These should use their facilities to attract medical tourists.
The Govt. of India should ensure that a part of the revenue thus generated goes into a corpus for ensuring the health needs of the poor and indigent. Medical tourism will also help to further improve the skills of our doctors and push down the costs of health care for the public at large.
Conclusion: The health care of a billion people cannot be provided adequately by the public sector alone. This will entail the commitment of massive funds, which the Indian exchequer can not afford. It is only appropriate, correct and necessary that the private sector shoulder some of the burden.
The private sector stool stands on three legs
1. Quality
2. Affordability
3. Ethical practice with tight fiscal controls resulting in reasonable profit
Profit making is not an ugly word but profiteering is: the sanctity of the dividing line must be maintained, never crossed, like the “Lakshman Rekha”.
Competing interests:
I am the Chairman of the Department of Academics and Research of a Trust Hospital.
Competing interests: No competing interests
Sengupta and Nundy need to be congratulated for having in their
article, brought out the irony of a country that is unable to take care of
the health of its own citizens wanting to take care of the health of the
world.
The argument that a focus on Medical Tourism does not in any way take away
from spending and prioritizing on Public Health Care has been made by many
who have responded. While this may be valid it still does not take away
from the fact that the serious lobbying by the Private Operators has been
a distraction to the Government in going about its work. When there is a
constant debate on whether the State should hand over its healthcare
facilities to the Private Sector and outsource its Healthcare Delivery and
with the media ready to lap up the stories issued by the PR Departments of
Private Hospitals on Medical Tourism it is difficult for the Govt.to
reaffirm to an increasingly sceptic public that it needs to get its own
house in order rather than sell out altogether.
What about the money the Govt. has already spent(and is continuing to
spend) in indirectly subsidizing Private Health Care? How many of the Free
Tests that were to be done when the Duty Exemptions were given for import
of Medical Equipment by Private Hospitals have actually been done for the
poor? Why should the Government Medical Colleges train doctors and nurses
charging fees that are ridiculously low and then not extract even a
minimum number of years of service in return from them? Why are there no
tariff slabs defined for expensive investigations to reduce the chances of
profiteering? (A CT Scan of the same body area can cost anything from
Rs.750/($17)- to Rs.7500/-($170) in the same city depending on the
Hospital).Why are Licenses given to Private Medical Colleges without
regard for their geographical proximity from one another and their ability
to serve a larger populace? (Example: Pondicherry, a tiny state has 4
Medical Colleges within a distance of 25 kilometres of each other and
another 3 are rumoured to be in the pipeline.)The list of questions is
unending.
For a majority of Indians a major illness in the family leads to
financial ruin. Unwilling to risk treatment at the State run facilities
the family spends its life savings and then borrows to the hilt to try to
save the patient and admits him to a Private Hospital. Within a week or
two the life savings and the borrowings are gone and for years together
the family struggles mired in debt. As Doctors working in India all of us
see such cases every day. Yet few of us ask the question-is this the only
way? Can there not be a system where the State if not providing for
affordable health care at least legislate to make health care in the
private sector itself more affordable?
Therein may lie one solution with the Govt. fixing tariffs for surgical
procedures , investigations etc. after categorizing Hospitals into
different tiers. One top tier could be left unregulated for the elite
Hospitals and the wealthy among the public too. If the Govt. can fix the
price for drugs, why not for tests and surgical procedures?
The Private sector is bound to resist this fiercely but the State has a
responsibility that it must fulfill. The lives of millions of Indians is
at stake.
Competing interests:
None declared
Competing interests: No competing interests
The rapid growth of private health care and decay in the public
health institutions has created a situation where the kind of health care
an individual gets depends on what he or she can afford! Thus while an
affluent person can get a cancer operation or coronary bypass or even a
live related liver transplantation almost overnight, the economically
backward sections of the society may have to wait for months for a simple
cancer operation or even die while on the waiting list – hardly a
flattering situation for a country that has the word ‘Socialist’ in its
preamble. The health care planners in India seem to have had scant respect
for the fabled ‘common man’.
In this regards, we have a lot to learn from the experience of other
countries. Having worked in the Netherlands recently, I believe the model
of the ‘Socialist’ health sector needs to be studied more closely. The
Dutch system caters equally to the health care needs of the
underprivileged sections and the rich. It is true that in a country like
India, government alone cannot provide for health care of the entire
population which now numbers over a billion. The experience of the city-
state of Singapore is noteworthy. There the government’s share of health
spending on an individual depends on his income – more is spent on the
poor and less on the rich. These are just two examples – there may be many
more from which we might learn…
It is not that there have been no benefits after the growth of the private
sector in India. The notable spin offs include quicker treatment, rapid
introduction of the state-of-the-art technology, a clean environment,
friendly staff and, most importantly, an accountability for work which is
sadly lacking in the public healthcare system.
There is an urgent need to evolve a suitable indigenous model to make at
least a minimum level of care available to all Indians, regardless of
their ability to pay for it.
Dr Dinesh Singhal
Consultant, Department of Surgical Gastroenterology
Sir Ganga Ram Hospital,
Delhi.
E mail: d.singhal.gis@gmail.com
Competing interests:
None declared
Competing interests: No competing interests
I echo many of the points made already in other responses that this
is an extremely timely analysis, but argue that the issue is grossly
oversimplified in Sengupta and Nundy's article. I have three points to
make: (1) India's private and public sectors are not suffering from unique
problems; (2) particularly in terms of technological advances, the booming
private industry can be benficial to public health; (3) a more complex
analysis needs to include discussion of ethics, rights and the brain
drain.
Private healthcare is not so different to any corporate entity, in
that, supply and demand are the two important determinants. There is a
relatively good supply of skilled medical and ancilliary personnel (who
are increasingly disillusioned with the public sector). There are supplies
of existing medical technologies and the capacity to develop new
technologies to compete with anywhere in the world. Within India, even
before medical tourism, there has been demand for a system which offers
"better" services. Therefore, towns in Kerala have some of the highest
concentrations of radiological and investigative laboratries in the world.
The demand from outside India has arisen because the quality of Indian
private hospitals can be equal to anywhere in the world, at a much cheaper
cost, AND the medical tourists are escaping from problems in their home
countries.
The problems with private medicine in India are seen in many
developing countries, and also in richer nations. The problems of high
health insurance costs, over-investigation, health disparities and lack of
insurance coverage are also rife in the United States. In the UK, seen by
many as the prototype for nationalised health systems, the private sector
has increasingly played a role in all aspects of medicine in recent years,
as the public sector cannot cope alone in an age of increasing demand from
patients and doctors. Raising the amount of funding as a percentage of GDP
is not necessarily the panacea for increasing the quality of health care.
In the US, a massive 15% of GDP is spent on healthcare and still there are
huge inefficiencies and disparities in the system. The problems of a
"small bucket" and "lots of holes in the bucket" are not unique to India.
Public health in India, a country of a billion people, is a huge
challenge in every way, but "private healthcare" does not necessarily
equal poor public health. It is poor management, corruption, bureaucracy
and other inefficiencies which are bleeding the Indian public sector and
damaging public health.
The Aravind Eye Hospital in South India, described by C.K. Prahalad
in his book "Fortune a the Bottom of the Pyramid", is an example of an
innovative method of delivering affordable health care to the rural poor
whilst maintaining quality and competitiveness within the urban Indian
market. The Aravind Eye Hospital has established itself as one of the
premier training institutions for ophthalmology internationally. This
remarkable venture was founded by Dr. G. Venkataswamy in 1976. It began as
an eleven-bed hospital and is now a chain of 7 hospitals across South
India with over 4000 beds. By 2004 it had screened over 5 million patients
and performed 2,225,225 cataract surgeries. Almost 70% of all surgeries
are performed free of charge (1).
The Kalam-Raju stent, India’s first indigenous stent developed
through missile technology by India’s current President Abdul Kalam and Dr
B. Somaraju, a Hyderabadi cardiologist, has brought down the cost of basic
angioplasty significantly, resulting in cheaper modern medical care for
the poorer sections of the community. The same group has also developed
India's first indigenous prototype cardiac catheterisation laboratory at
Care Hospital in Hyderabad, which should further reduce the cost of
treatment to a large extent (2).
We should not forget that it was the massive growth of the Indian
generic pharmaceutical industry which facilitated supply of antiretroviral
drugs to one-third of developing countries (3). Therefore, India's private
sector can benefit public health, within India and globally.
Finally, as well as the universal right to (public) health, doctors
and patients have a right to move freely. The movement of the former has
led to the brain drain over several decades, and the movement of the
latter has led to medical tourism. Both of these movements need to be
controlled so that public health is not compromised, and is actually
ameliorated.
1. Prahalad C.K. The Fortune at the Bottom of the Pyramid
2. Banerjee A and Rao B. Integrating Treatment and Prevention -
Ischaemic Heart Disease in India. www.procor.org
3.Will the lifeline of affordable medicines to poor countries be cut?
Consequences of medicines patenting in India. MSF Feb 2005
Competing interests:
None declared
Competing interests: No competing interests
The article made interesting reading, but the authors are confusing
many aspects which are inter related but not necessarily in a cause and
effect relationship. For Example, it is overinclusive to say that private
healthcare is cannabalising public healthcare.
Fact is that for years all policies, rules and laws have been gradually
amended by the GOI to suit interests of foreign practice and affluent
classes, medical tourism is only another facet. While the media cries foul
over migrating Doctors of all cadres, it is the GOI which has given an
undertaking of 'surplus' in medical skills to enable overseas recruitment.
The medical education is completely streamlined to acculturate young
doctors to practice Western medicine in Western settings.
Private medical enterprise suffers from real problems with sustainability.
It is not only greed, but also need which drives the age-old conflict
between commerce and medicine. With soaring land prices, equipment costs
in foreign currency, labour-intesive business model and lenghty time to
break-even; the average medical enterpreneur finds it difficult to qualify
for loans, repay them and run the household.
It will serve well for the GOI to stay away from either encouraging or
discouraging the foreign patient enterprise. It should certainly not enter
into treating foreign patients. Instead it should focus on its duty of
providing proper preventive and primary healthcare and effectively play
its regulatory role. In a perfect world the State should be responsible
for the health of its citizens(own citizens first), because good care gets
seriously jeopardised by commercial interests.
Competing interests:
None declared
Competing interests: No competing interests
Firstly, I wonder why the authors decided to publish this article in
the BMJ, which is not very widely read within India. Of course that it
wouldn’t have made any difference to the practice there, even if it had
been published in an Indian journal is a different matter altogether! But
the reason why the authors decided to bash the Indian system of medical
practice in a British journal is totally unclear to me.
The only relevant issue to the British public is that they would pay
a lot less for an operation even in any of the so-called five star
hospitals in India, for the simple reason that the value of a pound is
about 80 Indian rupees. But it is worth noting that a strong statutory
body like the general medical council is non existent in India. So, what
if something goes wrong? Who will follow up these patients after surgery?
Although patients go to India at their own risk, do they realise that most
of those doctors only possess Indian medical qualifications that are not
recognised by the general medical council?
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
First I congratulate the editorial board &authors for their timely
publication.
I completely agree with their views. But i want to stress the importance
of medical education in India.India is the best place to learn medicine
for its disease prevalence. No one could deny that even though private
hospitals doctors were trained in UK/US, they learn their basics in India.
It is time for them to repay the services to poor citizens. Private
Hospitals should allote some percentage of their services for free to poor
patients in need.
Competing interests:
None declared
Competing interests: No competing interests
The article by Sengupta and Nundy makes good reading though one fails
to see any connect between the burgeoning private healthcare sector in
India and the abysmal condition of the government healthcare system.
It is unfair to say that private healthcare is growing at the cost of
public healthcare. Let us place the blame where it ought to lay – the
government’s insufficient spending on healthcare. As Jean Drieze &
Amartya Sen point out in their book, India: Development &
Participation, while public spending on healthcare has been steadily
dropping, during the first half of the 1990’s, India’s defence budget grew
at a modest rate of 1.5% p.a. in real terms. Since 1996-97, the defence
budget has been growing at 10% p.a. in real terms. This sharp increase
contrasts starkly with worldwide decrease during the 1990’s. Would it then
not be appropriate to say that defence spending is growing at the cost of
public healthcare?
Patients will go wherever healthcare is available. If government
hospitals in India do not provide it then Indian patients will go to
private institutions. As patients from other countries come to India to
avail private healthcare so do patients from eastern India go to south
India for treatment at private institutions since these institutions are
perceived to offer better treatment than their counterparts in eastern
India. One or more of the respondents to the article have suggested the
levying of a tax on hospital bills of foreign patients to be credited to a
“fund for the poor” or diverting a portion of the revenue earned from
medical tourism to the government to be spent on healthcare. This is
ludicrous. Going by this analogy, patients from eastern India should then
contribute to the coffers of the state governments in south India. Also,
judging by the government’s penchant for defence expenditure, if a
percentage of the revenue earned from medical tourism is to be given to a
government fund, in all probability it will end in spending on defence.
There is a common or popular belief that private hospitals in India
make enormous sums of money by exorbitantly charging the poor patient who
seeks treatment at a private hospital because government facilities are
inadequate. Firstly, the private hospital being a commercial venture the
promoter is entitled to his return on investment. He does not claim any
altruistic motive, be it a nursing home set up by a private practitioner
or a corporate hospital. It is naïve to expect these entities to provide
social service in healthcare where the government, whose responsibility it
is to do so, has chosen to abdicate its role.
Secondly, one cannot deny the fact that private healthcare in India
is expensive for the Indian patient. This is so for a number of reasons.
28% to 30% of the project cost of a 100-bed hospital and upwards relate to
expenditure on medical equipment. This is a recurrent cost for hospitals
as obsolescence in medical equipment is high and it is further aggravated
by fact that most equipment in India is imported. Maintenance costs for
these equipment are high. Also, most medical and surgical disposables used
in critical care surgeries are imported. Contrary to what Sengupta and
Nundy writes, medical equipment and disposables imported by hospitals into
the country are subject to prevailing rates of duties. There are no
concessions in duties or taxes. So, there is a common saying in private
hospitals, “Spend in U.S. dollars and earn in Indian rupees”.
Hence, private healthcare is there for those who can afford it. The
moot point is what has happened to the government’s responsibility of
providing healthcare and where are the pressure groups who can influence
government spending in healthcare.
Berating private healthcare for not assuming the government’s role in
providing healthcare to its citizens is not the solution.
Yours etc.
Amitava Bose
Hospital Consultant-Facility Panning and Equipment Planning
Competing interests:
I disagree that private healthcare in India is growing at the cost of public heathcare
Competing interests: No competing interests
The main reason behind the growth of increasing private care in India
is the lack of proper infrastructure in the goverment sector.The goverment
sector is rampant with corruption in India and patients nowadays feel that
it's better to pay in private hospitals and get better care at private
hospitals.Another reason is that many private hospitals nowadays give
excellent care at affordable cost for the common man.In fact private health
care in India is rpaidly growing and perhaps I feel that Indian private
care in few years will challenge the best in the world.
In fact many patients from developed countries like UK etc are coming
increasingly to India for treatment.
Competing interests:
None declared
Competing interests: No competing interests
Defining Standards of Medical Education, Internship Training leads to lack of Public Health Knowhow in India
It is to be lamented that the common man continues to bear the repercussions of a weak and indifferent Public Health infrastructure in India dating back to 1947, when there was a lack of vision to strengthen it. That would have been the ideal situation to strik the iron when red hot!
Health authorities including policy makers and their red tape, along with bureaucratic myopia, added to the lack of Public Health knowhow; among emerging medical undergraduates, disillusionment concerning insecure career options adds to the woes. The doctor-population ratio is just a misleading number, considering nearly 500 Medical Institutions run the show with paltry amenities, forcing most doctors to seek greener pastures and orderly healthcare systems that unfortunately exist only beyond borders. The rest are forced to embrace the system as a matter of inevitable compromise decided by the ugly fight for existence, let alone survival.
There is a need to adopt a more realistic and sceptical approach rather than emotionally charged politically directed preferences that only make media headlines soon to dwindle in the darkness of optimism.
The wish then becomes for some messiah to deliver the disadvantaged sections of our society hitherto hailed except in exceptional cases with the aid of foreign media akin to Slumdog Millionaire!
Competing interests: No competing interests