Two recent incidents — the death of a seven-year-old in a Gurgaon hospital after her family was charged Rs 16 lakh and a 22-week-old baby being erroneously declared dead by a Delhi hospital — have triggered a debate on regulation in private healthcare. Dr Devi Shetty, the pioneer of low-cost cardiac surgeries, reflects on measures to revamp healthcare in India. The founder of Narayana Health, a chain of affordable medical centres, was once called ‘The Henry Ford of Heart Surgery’ by The Wall Street Journal and has been awarded the Padma Shri and Padma Bhushan
ABANTIKA GHOSH: There is an ongoing debate about regulating hospitals in the private sector. You have opposed the Karnataka Private Medical Establishments Act, which has proposed caps on the cost of healthcare, legal accountability etc.
See, when you try (to compare) firstworld regulatory structure with thirdworld infrastructure, you have a serious problem. The way the Act is designed, if it is implemented, 80 per cent of the small nursing homes and hospitals will close down in tier-2 and tier-3 cities. They are the only healthcare providers in that region. Every regulation will only add to cost.
We need to understand that this is a country which is working with 20 per cent of the required manpower. People pay a tiny sum of money compared to what it (treatment) really costs. Why does the government want to bring about regulation? They want healthcare to be safer and affordable for the patients. Are hospitals safe for patients? Just look at hospitals in the US. They are considered the safest hospitals on the planet. But if 200 patients get admitted to an American hospital and spend just one night there, one in two hundred dies due to medical error. It is not medical negligence. But getting admitted to an American hospital is 10 times riskier than skydiving. In the US, medical errors are the third or fourth most common cause of death.
Essentially, the government has to look at what is doable within our limitations. Look at our problems. Look at the nursing profession. We need two-three million additional nurses today. The attrition rate among the nurses across the country is 45 to 50 per cent. The profession is dying because there is no career progression for nurses. In the US, 67 per cent of the anesthesia is administered by nurses. In India, a nurse who has worked in the ICU for 20 years is legally not even allowed to prescribe a painkiller tablet. Why will people take up the profession? How can a hospital give her a higher salary? We have a serious problem.
First, provide all the infrastructure required for ideal healthcare delivery. Then, if they don’t deliver, you can look at creating regulations. Simply copying the regulation in the US and reproducing it here won’t work.
ABANTIKA GHOSH: Several medical associations abroad are actually part of a regulatory structure.
The regulations that we have for medical healthcare are exactly how they are in the US. We have a medical council (Indian Medical Association), which is an elected body that regulates our ethics and delivery. We are no different (from the West).
But in the US or in Europe, a doctor works for 48 hours a week. In India, doctors work for 48 hours a day. Yesterday I did three heart operations, saw 75 patients in my OPD. If I don’t see that many patients, the next day I have will have to see 200 of them. In the whole country, there are not more than 2,000 cardiac surgeons to operate on a population of 1.2 billion, right? So, if you expect us to give the kind of personal attention which every patient deserves, it is not possible. We can do better, no doubt, but for that you need to give us all the support system. We want the policymakers to look at everything holistically.
RAVISH TIWARI: How are we going to address the demand-supply gap in the medical profession?
We have a serious shortage of under-graduate and post-graduate seats. There is a reason why we hear of corruption and scandals in medical education. It is because there are very few seats. If 10 lakh people apply, and there are only 60,000 seats, naturally a lot of money will change hands.
Now, first let’s look at how a medical college is built. It costs Rs 400 crore to build a medical college. If you go to the Caribbean region, there are 35 medical colleges training fantastic doctors for the US in a rented 50,000 sq ft space. Why are we spending Rs 400 crore? It is ridiculous.
All over the world, medical colleges do not have this rigid requirement. Medical colleges don’t require 140 members to train a hundred students. In fact, 140 faculty members can run a medical college with a 1,000 students. So while the whole world has changed, we haven’t. We have made medical education elitist. Children from poor families are not dreaming of becoming doctors. This will have tremendous consequences. Most of the outstanding doctors across the world come from deprived backgrounds. These are kids with fire in the bellies, and they are ready to work for 24 hours to change the rules of the game. When children from rich families become doctors, they opt for radiology, dermatology and other such specialities where they can go home at 5 o’clock.
Why should post-graduate education cost so much? All over the world, higher medical education is free of cost. What is happening in healthcare is not because of the government, it is because the privileged society doesn’t ask the right questions. Why should a pregnant woman die during childbirth every 12 minutes; why do 3 lakh children die the day they are born? Why do 1.2 million children die before celebrating their first birthday? It is unacceptable.
Statistically, 14 to 15 per cent of pregnant women need a Caesarean section. That means we need to do nearly 5.2 million Caesarean sections per year. To do that, we need 2 lakh gynaecologists; we have 50,000 of them or even less. Half of them don’t practice obstetrics, because they don’t want to be woken up at night, and then all of them live in cities, whereas 60 per cent of children are born in rural India. We need two lakh anaesthetists; we have less than 50,000. We need 2 lakh paediatricians; again we have less than 50,000. We need at least 1.5 lakh radiologists and we have less than 10,500 of them. In such a situation how do you expect the maternal mortality rate to come down?
All this has nothing to do with money. This country doesn’t require additional budgetary allocation. This country requires the liberation of nursing and paramedical education. That’s all.
ABANTIKA GHOSH: Do you think the government should limit itself to training medical manpower and withdraw from running hospitals?
That will be a disaster. Interestingly, the Government of India owns the largest number of hospital beds in Asia. They have over 14 lakh beds. The private sector has only seven lakh beds. So, they (the government) are the largest healthcare providers. It will be a criminal waste if they don’t take part (in running hospitals). There is no financially viable model for running private hospitals in tier-2 and tier-3 cities. It is primarily because people don’t have the money.
We forget that we are still an agro-based economy. Seventeen per cent of the country’s GDP comes from agriculture, but 57 per cent of the country’s population depends on it. It is the government that has to run the hospital for them (people in rural areas). There is no question of working out a financially viable model to take care of them, unless there is a large scale insurance scheme like Yeshasvini (Co-operative Farmers Health Care Scheme, which provides cost-effective medical facilities to farmers in Karnataka).
ABANTIKA GHOSH: Is it fair for the private sector to say that we will only run hospitals in tier-1 cities, where we can make profits?
The private sector can build hospitals in tier-2 and tier-3 cities, provided the government creates a financial intermediary to pay for healthcare. I’ll give an example. We have 950 million mobile phone subscribers who spend Rs 150-250 per month just to speak on a mobile phone. If you ask them to pay Rs 30 per month along with their mobile phone bills, we can cover the (medical) cost for 950 million people, and then all the hospitals in tier-2 cities will become financially viable. But then there has to be a political will.
KAUNAIN SHERIFF M: How do we check the exodus of Indian doctors to foreign countries?
I was trained in India. After finishing my MS, I went to England and trained in cardiac surgery. Then, I came back. I would have never been what I am but for the British training programme. We should encourage all doctors to go abroad and learn, and then create a good environment for them to come back. We should never come in the way of human aspiration. If a hundred doctors leave, we should be able to create another 10,000 doctors.
There was a study which said that patients in the US are better off getting treated by doctors from overseas, than their own doctors. We have established Brand India as healthcare providers; it is the largest industry in the world. What we should really look at is how do we use this industry to create well-paying, meaningful jobs for our young people outside India. We should be the dominant healthcare providers for the world. We have a great opportunity. If we don’t do that, it will be a great injustice to the younger generation.
KAUNAIN SHERIFF M: When it comes to the issue of overcharging a patient, who do you think should be held accountable in a private hospital — the management, the corporates or the doctors?
It is very difficult… on the one hand you need cutting-edge infrastructure… If you ask me, every Indian must undergo surgery through a robot. The technology has not come to cardiac surgery, but it is a standard thing in abdominal surgery. Every Indian deserves the best technology. But then it costs money. So essentially, as healthcare advances, it is going to be very expensive.
We have been virtually pestering our policymakers to do the costing — find out how much it costs for a day’s stay in the ICU, the cost of one day of ventilator support. A neutral body must do the costing in a away that is acceptable to both the private sector and the government sector. But that hasn’t been done. So there is no way in which we can pass a judgment on whether the cost of treatment is fair or unfair.
Inside the hospital, no doubt, it is the doctor who is ultimately liable. But, if things happen because of the failure of the management, then the management is liable. There are very clearly defined rules and regulations. The medical council investigates all the treatment protocols. We have enough regulatory bodies. The addition of one more regulatory body to investigate things is not going to make a difference.
SUNIL JAIN: In case of Delhi’s Max Super Specialty Hospital, where a 22-week-old premature baby was declared dead erroneously, should the hospital have done some more tests?
See, in some cases, such foetuses can survive for a few hours, and they can stop breathing and then start breathing again. It is very difficult to give a judgment based on sketchy data that we have. But, I just want to explain one thing: if you park an OB van outside any 200-bed hospital, you will have at least two instances of medical error with heart-wrenching outcomes everyday. In the healthcare industry, even with maximum safety standards, there will be that many errors. This is happening in the US. I’m not talking about India.
…The media has created such a hostile relationship between the doctor and the patient that we are forced to only do things which are legally right. We have to understand that there are sentiments of people involved. Today, patients look at us (doctors) as people who are out to cheat them. The trust has been broken. It shouldn’t have been that way.
Now if somebody dies, straightaway it’s called a mistake. Hospital has done this, hospital has charged Rs 16 lakh… There are patients who undergo procedures in my hospital where the bill is Rs 30 lakh. This is an industry where there are tremendous limitations and people have no money. The trial by the media has made us very careful.
ABANTIKA GHOSH: Isn’t that very element of trust the reason why market forces cannot be allowed to decide healthcare expenses?
In every profession there are good and bad people, and the medical profession cannot be an exception. Now, just because some people took advantage of their position, you cannot paint everyone in black, that is not a fair thing to do. We have to be cognizant of the holistic picture and then take action.
JYOTI MALHOTRA: Does the medical fraternity reach out to the government and vice versa?
It is very difficult to answer that question. All I can say is that it is difficult to wake up people who are not sleeping. But I also have good news to share. It is about my experience with Union Health Minister J P Nadda. I met him about a year ago and talked to him about the CPS (diploma courses granted by the College of Physicians and Surgeons in Mumbai). I wanted the Medical Council of India to recognise the degrees across the country, and I never expected it to happen. But on Diwali, the government did it. So it’s is not that the government doesn’t do its job, they do it. But then it requires tremendous persuasion and a willing minister.
UNNI RAJEN SHANKER: You said that under the Yeshasvini scheme, the Karnataka government pays back 30 per cent of the cost incurred on a surgery to the hospital. So how do you get the rest of the money?
Private healthcare works on cross subsidy; we just need 40 to 50 per cent of our patients to pay the market rate, and some premium. Then, about 10 per cent (of the surgeries) can be virtually done for free. For the remaining 30-40 per cent, we can pay the actual material cost, or maybe less. So essentially, it is a numbers game.
KAUNAIN SHERIFF M: Earlier this year, the Prime Minister said that he will bring in a rule which will make doctors prescribe generic drugs over branded ones. What is your view?
See, in a lot of countries you can’t prescribe branded drugs; you have to give the original name of the drug and then the patients choose which one they want to buy. In India, there could be a problem here because the pharmacist will decide what medicine the patient takes. Now, that may not be in the best interest of the patient because the pharmacist might give him something which is not up to the mark. In our country, making medicine is like a cottage industry. You can make medicines in your backyard. There are more than 10,000 or 20,000 pharmaceutical companies, unlike the West where to set up a pharmaceutical unit you have very rigid guidelines. So we have to fix things.
The Prime Minister’s desire is perfect, but we have to make the industry suitable to that. There can’t be 10,000 companies making medical drugs with very poor standards. The entire purpose gets defeated.