The recent concern about healthcare is not new, nor is the demand for an effective watchdog. There are many watchdogs in India. But they seldom bark or bite. In healthcare, the reason for this lies in the absence of implementable norms. A watchdog without norms is toothless. For hospitals, this translates as the need to have protocols and standards of healthcare that put patients first. The government already has sufficient investment in healthcare that could be used to leverage and implement the protocols without arm-twisting.
But political will would have to be generated for that, since hospitals, major resources for political parties and leaders, will resist this.
Few people realise governments in India already spend over Rs 8,000 crore per year in various health insurance and insurance-like schemes. At least two-thirds of this goes to private hospitals. Andhra Pradesh, Tamil Nadu and Maharashtra have already brought the majority of their populations under health insurance. Others will soon follow.
Making some simple changes to the law and in the implementation of schemes will ensure that this money is spent more in the interest of patients rather than in the interest of hospitals and insurance companies. Maharashtra alone has linked insurance reimbursements to the observance of standard clinical protocols, the essential benchmarks of good practice. The issue of clinical benchmarks of care is certainly a complex task, but doable. All that Maharashtra did was ask the best doctors in the country to put their heads together and come up with the requisite protocols. This difficult task was completed on a priority basis.
Certainly, there are enough consultants in India who care for good practices. One result of this was rationalising decision-taking and making it less arbitrary. If, consequently, the incidence of angioplasty, for example, came down by 20 per cent, did it imply unnecessary procedures in the past?
For observance of protocols, hospitals need to keep records of treatments in a systematic way. That is almost entirely missing currently. “Too costly, time-consuming and of no real immediate value,” is the response from hospitals. Not that hospitals don’t maintain data. That which impacts their profitability is rigorously maintained — how many patients treated, procedures done, the outgo of consumables, etc. It is data pertaining to the response of patients to the caring efforts that is missing. Could such absence be cause for suspicion?
One result of the lack of record-keeping is that it is difficult to red-flag bad practices. The Rashtriya Swasthya Bima Yojana, for example, does not have any pre-authorisation mechanism for treatments. That allowed for, inter alia, suspect treatments being offered. Some would still recall the thousands of questionable hysterectomies conducted on unsuspecting women in Rajasthan, Bihar and Chhattisgarh.
Andhra imposed a ban on private hospitals doing such procedures, but this can hardly be a solution when the private sector is the backbone of our medical system today. In fact, standard rules for medical treatment and record-keeping have been prescribed in various textbooks for many decades now. Textbook rules put patients first. It is just that no one seems to follow what is prescribed. Patient-care seems to be largely missing from the norms hospitals follow.
Keeping patient records requires investment in time and manpower. Since the law is silent on the matter, hospitals resist any request for record-keeping. Even in the case of extreme events like death, hospitals do not collate procedure-wise statistics. That task is left to the media when things seem to grow out of proportion.
Surely, hospital profits need not be based on denying the patients’ interests. For instance, the textbook norm is that a patient be tested for fitness for anaesthesia a day before surgery. Many hospitals insist this be done on the operating table and the patient certified as fit. The real problem is that hospitals, left to themselves, have no incentives to follow protocols. Following standard protocols or keeping records of patient outcomes is not linked to package rates for hospitals. Maharashtra is one state that has made some attempts to use such norms for the empanelment and grading of hospitals. The results seem to be positive.
Patients continue to confuse the reputation of the hospital with that of its consultant doctors. Few realise that doctors are hemmed in by the hospital’s rules. As such, the doctors need to be empowered institutionally by making these norms part of the social contract with the hospital.
A hospital is a business like any other. It responds to economic incentives or legal requirements. The key lies in, first, creating rules as Maharashtra has done and, second, in being able to link the maintenance of the quality of care standards with payments made to hospitals through insurance schemes or otherwise. Outcomes of treatment need to be tracked in terms of better-healing, reducing post-treatment depression, reducing the need for re-hospitalisation and lower death rates.
Unfortunately, these are of little value to hospitals in India. Revelling in large amounts of money spent on healthcare is fine. Now we need to put in place systems that ensure the money gets spent in the interest of the patient.
The writer is secretary, health, government of Maharashtra. Views are personal