CONTENTIOUS ISSUE
Sachin Landge
The Drama and The Tragedy of Indian Healthcare
"One doesn't need to be a doctor to start a hospital, just as one can start a hotel without knowing how to cook".
Big businessmen and corporates who must invest their money in profitable ventures knew this very well. Up came gigantic buildings under the title 'advanced / world class healthcare', where much was invested in the infrastructure and technology, but the quality of doctors was kept to bare minimum necessary: junior most who are willing to accept the atrocious sharing conditions. These new 'Money Making Machines' picked up very well, because they gave the rich class an illusion that they can buy health with money, but also attracted the middle and lower classes under the ever-coveted term 'cashless'. The fear of illness and death was exploited with aggressive marketing. Many things started to change after 1992.
When one invests in many hundred crores, the profits must match. To maintain, there must be continuous patient flow, admissions, tests, procedures and surgeries. Indian society is quite vulnerable to advertising as well as corruption. All the marketing strategies and skills were aggressively employed in that direction. To catch patients for paying procedures and surgeries, to develop a patient base, free camps were arranged in the interiors. 'Free' is a universally loved term, most people blindly fall for it.
The idiotic term 'whole body check up' was invented to attract the illiterate, ignorant and hyper-anxious crowds. Unnecessary tests were suggested and done happily under the false sense of health security. PROs and marketing teams of various hospitals started visiting private doctors for the obvious: commissions on admission / tests / surgery.
Patients with even simple illnesses that can be treated at primary healthcare center were taken to bigger cities now, and they proudly boasted how much land they sold to get the right treatment. The perpetual inadequacy or absence of federal / state healthcare infrastructure was never questioned. Those who had insurance cover started thinking that they now own all the hospitals and doctors. They started behaving as if they are obliging the doctor / hospital by choosing them. 'Only a good outcome is must because I am paying money' became a universal expectation, and thanklessness, threats and vandalism started with almost every bad outcome.
Applying the consumer protection act in India, with high illiteracy, poverty and political interference was the final straw. Doctors now could not treat patients based upon only clinical judgement, because the patient and the courts would demand proofs. So tests became necessary, to the point of finding a proof. Evidence based medicine defeated the need for clinical judgement to treat simple conditions without having to do the tests. Doctors and patients both started to suspect each other, and grew apart.
Still some really patriotic doctors, clinics, smaller nursing homes and hospitals continued what was essential for the society, giving excellent healthcare at the lowest cost, based upon their patient base generated over decades of faith and trust. The 'Clinical Establishment Act' broke the very spine of such hospitals, because it made western standards blindly mandatory for Indian hospitals. More licensing, over 30 permissions (bribes everywhere), and so much paperwork and infrastructure investment, that it was now impossible to keep healthcare low cost. The only thing that was excluded from such westernization was costing. As the doctor is the only face of healthcare for the patient, the ultimate blame for higher costs was conveniently placed upon his/ her shoulder. All doctors turned villains now.
The hidden plans to eradicate small hospitals and private practitioners are being successful now, given the hardships involved in running one's own hospital. Thousands of small hospitals / clinics have closed down. Doctors now must join corporate hospitals if they want to continue as specialists. They have no control over billing and hospital policies, and are thrown out if they question anything. Most people do not know that a doctor's payment is less than 10 percent of most hospital bills, a standard corporate protocol all over India, and if the doctor wants to help the patient, it is his own bill that he/ she will have to sacrifice.
Mediclaim (Medical Insurance) is still at a fraudulent stage in India, with many deserving patients being denied insurance, while many patients being allowed to misuse it. Mediclaim companies now have two fatal policies; to encourage the accreditation business, thereby making it difficult for smaller hospitals to survive, and to dictate lowest healthcare costs for hospitals and doctor's fees, whereby their own profit margin stays high. In such a scenario, the corporates either must inflate the bills or cut down on the quality of healthcare provided.
The big corporates required specialists who worked at the lowest salaries and accepted all their conditions. Those who had passed out without much merits from less academic medical colleges, those who had lower confidence and / or experience became easily available. Instead of increasing govt medical colleges and seats, private medical education was encouraged, because the highest in the land prifited from that policy. The society never objected, because the dream of 'buying a medical seat and ability of becoming a doctor even without merit' had become a reality. Only a few exceptional students benefit from private medical education.
To pay for electricity and water and land and building with commercial rates, to get no subsidies, to pay full taxes, and then to be told to "subsidise" patient bills for charity (whereas the govt hospitals keep on increasing it regularly), is atrocious. At every stage a hospital / doctor must bribe for permissions. Very few exceptions. In fact, people expect doctors to pay higher bribes. Doctors belong to the same society as you, and mirror the same good and bad that the society has, there cannot be one-way blame game here. This does not mean there weren't greedy doctors, in fact the corporate policies helped some such doctors flourish too.
There indeed were days when doctors earned too much money, some with good and some with deceptive means. Gone are those days. Now in each specialty there are a few who do well, and some who don't. Most doctors struggle to maintain the incomes to continue offering good healthcare. Many have quit the profession.
Even patients are mostly not happy with only honest and good treatment. They want multiple facilities and luxuries, trained staff, accreditations, cashless facility, no marketing/ referral/ cut practice, but still the lowest rates. How will smaller hospitals compete in such a scenario with the giant corporates?
In a few months / years, small hospitals and private medical practice will have been completely eradicated, the only healthcare options will be government or corporate. After defaming the entire medical profession and creating wide rifts between the society and doctors, the marketers of health and life corporates and insurance companies, will keep on freely filling their coffers while providing compromised healthcare at all stages.
( Sachin Landge, Anaesthesiologist, Ahmednagar. Translation: Dr. Rajas Deshpande)