Indian Hospital Services and Secret of Behind this gameIt is the worst kept secret. And yet when David Berger, an Australian doctor, recently wrote in the `British Medical Journal’ (BMJ) about his experience of working in a hospital in India and the rampant corruption that plagues the healthcare system in this country, it drew two extreme reactions. One was that there were of course a few bad eggs but in the main all was well.
The other was that large scale exploitation of patients was a reality which the government as well doctors must accept. Dr Samiran Nundy, gastroenterologist and surgeon at Delhi’s Sir Ganga Ram Hospital, reacting in the ‘Current Medicine Research and Practice,’ which he edits, admitted that after “working for 38 years, both in the public and private sector, I could not, unfortunately, agree with him (Dr Berger) more. The process of individual corruption starts early, with the capitation fees for entry for the MBBS course in many of the now ubiquitous private substandard medical colleges which are mainly owned by politicians.”
According to the Medical Council of India there are 160 government-run and 180 private owned medical colleges in the country. Together they account for 63,800 MBBS seats. The share of the private colleges in this pie is 38,715. In fact in states like Karnataka, Maharashtra, Andhra Pradesh and Kerala government-run institutions are less in number than those run by trusts and private enterprise. In Karnataka, for instance, there are 43 medical colleges of which 32 are private. In Andhra out of 40 institutions, 26 belong to the latter category. But, despite the large number of seats, getting admission is difficult. This is because medicine is a much sought after profession and private institutions prefer students who are willing to pay huge capitation fee.
Writing in The Hindu last year, Sujatha Rao, former Union Health Secretary, focused on what ails private medical education and how it serves the cause of rich students. To quote: “India is the only country that authorises, as official policy, the sale of medical seats by private medical colleges, implicitly accepting the principle that the ability to pay, and not merit, is what counts. Further, in the absence of any system of third party certification by way of an entry or, more importantly, an exit exam — which could guarantee the qualities and competencies a doctor must possess before starting to practice — many medical colleges are producing quacks. The tragedy is that we all know about it.”
According to insiders, if you add up the legal and illegal amounts paid for an MBBS and postgraduate seat, then the money spent by a prospective student for securing admissions ranges anywhere between Rs 50 lakh to Rs 1 crore. According to Dr Berger, corruption in the education system is what leads doctors who have invested large sums of money on their education to use every opportunity to fleece patients and recoup their investments. It also makes them opt not to work in rural areas and favour practicing technological medicine for maximum profit in urban centres.
At the receiving end of the cycle of corruption is the ill-informed patient. Doctors are loath to publicly admit it, but they will tell you that they know of private-run clinics and five star hospitals which insist that unnecessary but expensive diagnostic investigations like MRI and CT scans be carried out on every patient. In return the doctors get their cut from the labs that conduct these tests. But that is not where it ends. Surgery is often recommended when it is not required, cardiac procedures are carried out when medication is enough and expecting mothers are put through a Caesarean Section and encouraged to have assisted delivery which is costlier.
A few years ago a photographer colleague had a burning sensation in his chest and went in panic to a clinic in East Delhi. After verifying that he was covered by medical insurance he was told that he would have to be kept under observation and subjected to tests and perhaps a surgery since the doctor suspected he was suffering from a rare cardiac condition. Here was a young man in his early twenties being told that he was a heart patient. Luckily he fled from the hospital, and sought a second opinion from a government doctor. He was informed that he was in fine fettle and that he was merely suffering from heartburn and all that was required was an ant-acid tablet!
This must be an odd though shocking case. But unscrupulous private hospitals are known to extend the hospitalisation of patients to maximise profits. A doctor I know who worked in a hospital in Bangalore told me about administrators who calculate bed to patient ratio and determine when someone admitted should be discharged. And this applied even to patients in the ICU who are kept on the “serious but recovering” list much after they should have been either discharged or moved out of intensive care. The hospital seemed to have no consideration for the relatives of the patients who can do little but worry and wait.
Dr Aniruddha Malpani, an IVF specialist who runs a well known infertility clinic in Mumbai is a campaigner for better informed patients and improving patient-doctor relationships. In one of his blogs he writes about how patients are exploited by hospitals. According to him, hospitals make it an unwritten rule that those admitted should repeat tests even though these were done only a few weeks ago. Writes Dr Malpani: “It’s very easy for hospitals to justify over-testing by saying – this is our hospital policy. The patient’s physician is also helpless; because he also needs to follow the rules of the hospital and cannot carve out exceptions for his patient, no matter what his personal opinion maybe. This kind of mindless decision-making is not very helpful for anyone concerned, except for boosting the hospital’s profits. It does not improve the care provided to the patient; and the unnecessary duplication of tests wastes money and causes pain and discomfort.”
Dr Berger’s observations are quite revealing. He points out that Indian healthcare system is an inequitable one and among the most privatised in the world. He says this is thanks to the World Bank backed policy introduced in the 90s which reduced public financing for healthcare so as to encourage the private sector. As a result you now have a situation where latest procedures and equipment are available for the rich while the overworked government health system is what serves the vast majority.
Very clearly to rescue medical education and healthcare from the mess it is in now requires the political will to reform the system. But that is very easily said than done. Both private hospitals and medical colleges are run by powerful lobbies which are well connected across political parties. Hence, monitoring them would be difficult. However, that has to be done to reverse the merit over money policy that rules in a sizable number of private colleges. Also, hospitals have to be made more accountable and not allowed to exploit patients. Last but not the least, the beleaguered public healthcare system needs urgent attention. If not, the government will be failing the people.