Beef bans by state governments and killings by self-styled cow protectors remind us, almost on a daily basis, of Article 48 of the Directive Principles of State Policy in the Indian Constitution. It counts prevention of cow slaughter as a state obligation. The Article preceding it has, however, been consigned to oblivion. Here’s what it says: “Duty of the State to raise the level of nutrition and the standard of living and to improve public health: The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health.” In other words, according to the Constitution, public health is as much an obligation of the state as protecting cattle.
Yet, from around the time when India opened up its economy, the government has increasingly ceded space to the private sector in matters related to health — that is the root cause of the current controversy over billing methods in private hospitals. The controversy erupted after a seven-year-old girl, Aadya, lost her life due to dengue-related complications in Fortis Hospital Gurugram last month.
The growth of the private sector — largely unregulated — is, in fact, less a statement of its efficiency than a result of the government’s failure to provide affordable, accessible and equitable healthcare. As the demand-supply gap widened and the government found itself incapable of providing quality healthcare, the private sector moved in swiftly, becoming the health set-up of choice for all except the poorest. A 2007 paper in the Economic and Political Weekly notes, “high absenteeism, low quality in clinical care, low satisfaction levels with care (clinical and with regards to courtesy and amenities) and rampant corruption plague the [public health] system.”
According to the report of the High-Level Expert Group (HLEG) formed by the erstwhile Planning Commission to look into how India could move towards universal health coverage, “From 8 per cent in 1947, the private sector now accounts for 93 per cent of all hospitals, 64 per cent of all beds, 80 per cent to 85 per cent of all doctors, 80 per cent of out-patients, and 57 per cent of in-patients.” Of the 1.37 million functional hospital beds in India, 8,33,000 are in the private sector, according to the report. This is despite the fact that international experience and countless academic papers have suggested that tax-based public financing is the ideal health finance option along with social insurance — or private insurance for those who can afford it.
There have been sporadic and half-hearted attempts at regulation. The Clinical Establishments (Registration and Regulation) Act, 2010, intended by the Centre as a model legislation for the regulation of hospitals by state governments — health is a state subject — has had a low uptake. Standard Treatment Guidelines that were drawn up for specific conditions and diseases, to obviate overprescription of drugs or additional costs of diagnostics, remain documents that nobody takes seriously — few doctors have perhaps even read them, given that there is neither monitoring nor an enforcement mechanism that can pick violators. The West Bengal Clinical Establishments (Registration, Regulation and Transparency) Act, passed earlier this year, and the Karnataka Private Medical Establishments (Amendment) Bill, 2017 — that was recently tabled in the Karnataka Assembly — have been criticised as draconian. The two acts have penal provisions against doctors who overcharge.
Insurance companies have an interest in vetting private hospital bills and that could work as a de facto check on false billing. But health insurance has penetrated only 3-4 per cent of the country’s population. That Aadya’s family was billed for 611 syringes, 1,546 pairs of gloves (used over a period of 15 days) and two different brands of the same drug meropenem, one costing about Rs 500 and the other Rs 3,100, underscores the need for regulating billing in private hospitals.
The National Health Policy 2017 cleared earlier this year by the Union cabinet lays out a roadmap for public-private partnerships in healthcare. Recognising that primary care will forever be in the domain of the government, the policy talks of “strategic purchasing” of secondary and tertiary care from the private sector. For that to happen, especially in a price-sensitive ecosystem such as India, it is important that either the private sector raises its trust quotient or the government devises an effective regulatory mechanism to drill transparency into the private healthcare system.