Earlier this month, The Lancet published a paper calling for a radical transformation of the architecture of India’s healthcare delivery system if it is to achieve the government’s vision of assuring health for all. The paper documented India’s progress on major health indicators in the past decade, but also its many deficiencies. The most disturbing indicator of these deficiencies is the observation that the cost of healthcare is driving millions of Indians into poverty. Let us pause to consider the implication of this statement.
In a country where the primary goal of economic development is to help raise people out of poverty, healthcare is driving millions into poverty. Whereas, in other countries, investment in healthcare is recognised as a route to promote growth by enhancing their citizens’ capabilities to be productive, healthcare in India is now one of the leading causes of poverty. We are, in simple terms, out of step with the rest of the world, not only the developed countries whose ranks we aspire to join, but also with other countries like ours.
It is common to lay the entire blame, or at least the lion’s share, for this on the government. This is certainly true to some extent, but the reality is that many sectors must share this blame, not least the medical profession, of which I am a member. In most countries, the medical profession plays a central role in working with the government and civil society towards improving access to affordable, quality care. In India, though, the medical profession is adrift from any alignment with this vision and is, if anything, increasingly seen as being complicit in perpetuating our abysmal health care system, and as an obstacle to a progressive one.
Hardly a day goes by without us being reminded of how corruption of the basic values of respecting patient rights and promoting an evidence-based practice has reduced our professional standards to those where doctors effortlessly associate with crooked politicians and police officers. Consider some stories that illustrate this: Illegal payments for approval of and admission to private medical colleges; falsification of faculty records to meet the criteria for recognition of these medical colleges; unethical and irrational practices of unnecessary procedures, diagnostic tests and hospital admissions with a commercial incentive; kickbacks in cash or kind from companies or other physicians for prescriptions or referrals; fraudulent billing for insurance payments; lack of attention to quality of care leading to catastrophic health outcomes following routine surgical procedures; collusion with pharmaceutical companies to run “health camps” whose primary goal is to create markets for the company; and collusion with families to promote sex-selection.
While much of this corruption lies in the private sector, now the dominant force in healthcare delivery in India, it is equally the case that corruption is also evident in the public sector. Consider absenteeism to run illegal private practices and the lack of basic dignity in healthcare, both frequent observations in the public system. It would be fair to say that the reputation of my profession has collapsed since I was a medical student in the 1980s.
While many of my colleagues may argue this is unjustified, I doubt if any will deny that a radical revision of our healthcare system will need to be accompanied by a radical revision of the medical profession itself. This reform would need to begin from the very nature of the training our medical students receive, so as to prepare them not only to work in specialised urban hospitals but also in primary care in villages and towns.
The reform would need to extend further, much further, to regulate the quality of care delivered, to make costs of care completely transparent in the spirit of the Right to Information Act, and to hold doctors (and hospitals) accountable for wilful lapses. The most formidable challenge to this goal has been the complete squandering of the golden opportunity afforded to our profession for self-regulation through the Medical Council of India, which is itself accused of grand levels of fraud and has singularly failed to achieve its mandate to uphold the high standards of medical education and quality of care. Any reform must begin with a root and branch re-engineering of this moribund body. Ironically, while we have failed to effectively regulate ourselves, our profession has also mounted a robust opposition to independent efforts to regulate us, for example through the clinical establishments act. This leaves an increasingly disgruntled patient community to resort to the consumer protection act and the criminal courts to hold us accountable. This procedure only poisons the precious relationship between our profession and the community we serve.
Whereas the erosion of many fundamental values, such as that of providing scientifically grounded care in an environment of respect and dignity, will require a significant revision of training and continuing professional development, attending to commercially driven malpractices is more amenable to immediate action with potentially profound impact on impoverishment due to healthcare. The Jan Swasthya Abhiyan recently demanded that “all payments of kickbacks and commissions” be declared as illegal and compliance be