Dr. Sudarshan Ballal’s article – Conflict of interest

Dr. Sudarshan Ballal’s article in Deccan Herald published on the 28th of June 2017 calls for a counter. He talks about controversy and mistrust being generated between the medical fraternity and the state government by the introduction of the Karnataka Private Medical Establishments (Amendment) Bill – 2017. While it is somewhat ironic that patients and citizens figure nowhere in this equation, it also needs to be stated that historically the private sector has held the government to ransom at multiple levels of policy making, budgeting, allocation of scarce healthcare resources and patient rights. In fact, it would have been closer to the truth if the writer had said that patient rights and private hospital rights are at logger heads with each other, with the former most often taking a backseat to the latter. His second point about the unusual situation of doctors taking to the streets in protest against the Amendment is true, but it also makes one wonder why doctors don’t take to the streets when patient rights are denied, when costs are so exorbitant that patients and families are forced into poverty, when negligence happens and when empanelled hospitals fleece the government and refuse to be accountable.

The idea of healthcare as a free market economy which cannot come under any form of price regulation, is highly problematic. A market commodity often comes with a large element of choice to the consumer unlike a health care need. If a person wants to buy a commodity he or she can make the choice based on budget and even choose not to buy it if it is beyond one’s budget. Catastrophic health expenditure, at the other end of the spectrum, removes any notion of ‘choice’ and instead makes people extremely vulnerable – it is this choicelessness and the extreme power hierarchy between a doctor and a patient, that makes it dangerous to bring health under the purview of market logic. Dr. Ballal’s concern that small hospitals and mission hospitals in Tier 2 and Tier 3 cities will be subsumed under this Act is in fact untrue. These hospitals are in much more danger of being subsumed under the National Accreditation Board of Hospitals (NABH) standards, which the private sector is desperately trying to force even on government hospitals, knowing fully well that it would be the death knell of government hospitals that work on different standards and principles. The Amendments to the KPME would in fact level the playing ground for smaller hospitals and nursing homes to offer services to patients closer to their homes and towns.

The use of the word ‘control raj’ by Dr. Sudarshan for something as important as regulating what one does and doesn’t do with human life, is offensive. Regulations and price caps need not be at financial cost to the private establishments, it is just to ensure that patients are not unnecessarily fleeced off lifetime of savings. The recent national news of patients being charged anywhere from 1000 to 2000% more for cardiac stents is a case in point.

It is true that the private sector is filling a vacuum created by lack of facilities in the public sector. This only goes to show that public sector has to be strengthened with investment in human resources, training, drugs, infrastructure, residential facilities etc. as well as an adequate budget and a strong regulatory mechanism. How this then goes on to mean that the private sector should not be regulated is unclear.

The argument of Dr. Ballal that tax payers pay for public healthcare is true but he fails to mention that empanelled hospitals under various schemes of the national and state government are receiving huge sums of money from the same tax payers’ money which makes the private sector all the more accountable. That private hospitals receive huge subsidies, land grants, loans, tax exemptions, import duty exemptions are left out of this argument rather conveniently.

It is also interesting that the doctor says that there are some rotten apples in the medical community and it is unjust to label the entire community as corrupt and dishonest. This a clever play on words. At no point has the argument in favour of the Amendments been to label doctors as corrupt or dishonest. The effort has always been to bring the so called ‘rotten apples’ under rule of law so that patient’s rights are not violated on a day to day basis.  Asking for regulation and labelling doctors as bad people are two different things and one can’t be used interchangeable with the other. It is also a case in point that the Amendment is largely focused on regulating Medical Establishments and not set out to humiliate doctors who are a vital part of ensuring health for people.

When the discussion on way forward takes place, the focus is squarely shifted to the public sector. So the question is, if all the suggestions regarding strengthening of public sector are implemented on paper and in spirit, then does it mean that private sector should not be regulated? It does not. In fact, one way of strengthening the public sector has to be pre-empted by reigning in the private sector so that it functions as an integral part of a larger health system and not as a law unto itself. It is well known that private hospitals have no mechanism of reporting data on morbidity, mortality, caesarean sections, hysterectomies and other surgeries. There is poor documentation and maintenance of records for the rationale (if any) behind investigations and treatment, referral patterns and cause of death, if it occurs. Patients therefore have very little access to information if they would like to have a second opinion, which they are entitled to, or if they suspect negligence and would like to pursue the case legally. The public health system has a more rigorous system of data collection and transmission, which helps to understand disease and mortality, as well as diseases of public health concern.

It is unfortunate that the doctor compares the USA and UK model in one sentence. As is well known, countries which have a strong public health system like the NHS are better able to deliver healthcare in a comprehensive and equitable manner. One need not look as far as the UK. We have examples with our own neighbours like Sri Lanka and Nepal which have invested in public health and had good health outcomes.

The doctor says that there are already many regulatory bodies like the medical councils, consumer courts and the judiciary to protect the citizens and adding one more layer will only lead to more confusion. These bodies, as can be vouched for by many  human rights groups and patients seeking redressal, are a maze deliberately set up to protect the doctor. It is also well known that in cases of negligence and denial of care by private hospitals, expert doctors very rarely testify against colleagues even in obvious cases. This makes patients and their relatives extremely vulnerable and puts them completely at the mercy of medical establishments, with doctors as experts.  Why should there not be a dedicated body that is accessible to patients and their families, that looks at patient rights and holds medical establishments accountable for delivery of good quality care?

The real agenda of the private sector comes out in the last sentence of Dr. Ballal’s article. The government as role of insurer is a fancy way of saying that on the one hand the government should ensure that an endless supply of money and ‘lucrative’ patients are directed to the private sector but on the other hand, it should not impose any kind of regulatory strictures on costs or intervene where there are patient rights violations. This would however make it a government for the private sector rather than a government for every last citizen of the state –irrespective of their religion, caste, language, class or paying ability.

Dr. Sylvia Karpagam

Public health doctor and researcher.

9916509960

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