Previous efforts to control private sector costs have failed.
It’s a scary experience that you have certainly heard of. A sudden health crisis results in hospitalisation. Several tests, drugs and procedures later, the patient and family are facing crises on two fronts — the illness and humongous costs. After discussing the patient’s condition with an anxious family member, there is another inevitable gloomy interaction: “Doctor, we have exhausted our resources. Can you do something about the bill?” Out-of-pocket costs and impoverishment due to illness are among our gravest societal tragedies. Resentment towards costs is a big factor in the growing hostility, including violence, against healthcare workers.
This is why, when the Supreme Court recently spoke strongly on this issue it resonated with many. The Bench was hearing a PIL by an NGO praying for direction to determine charges in hospitals across the country in terms of Rule 9 of the Clinical Establishment Act. The Court threatened to impose the Central Government Health Scheme (CGHS) rates on all hospitals as an interim measure. It gave the state six weeks to act. Is it possible for the top court to intervene effectively where governments have failed? What exactly is it wading into?
If there is one policy which should be prioritised by a nation that genuinely cares for its citizens, it’s the elimination of money as a precondition to relieve suffering in an illness. What comes closest to this aspiration is a publicly funded health system which gives timely, effective and free care, irrespective of social class. Countries with universal healthcare ensure that no one pays at the point of care. Funding comes from taxes. Thus, the rich subsidise the health of the poor and everyone uses the same facility. So, if you are knocked down on the road or suffer a heart attack, needing instant lifesaving care, whether you live or die is not determined by money or social status.
Following Independence, India’s professed policy was to attain universal health care. However, deliberately or through benign neglect, the state underfunded public facilities, making space for an alternative to emerge. The elite, desiring healthcare designed for their needs, started building big hospitals. Some started as charity, but most soon realised that healthcare is lucrative. They were also unwittingly bailing out the state by establishing high-end curative services which had been ignored in the preoccupation with primary care. This process took a big leap after liberalisation when for-profit hospital chains funded by investors and global capital entered the fray. Private hospitals provided efficient, sanitised and high-tech care compared to public hospitals. The middle class shifted to them.The poor also soon began to prefer private care. India now has the distinction of having the largest private healthcare sector in the world. But that’s only part of the story.
There are other characteristics crucial to understanding private healthcare in India. First, a universal truth: Healthcare does not follow market rules. It involves unpredictability, distress and relies on empathy. That’s why even dominant market economies insulated healthcare. Secondly, healthcare in India is one of the least regulated. Anyone can start a hospital anywhere, promote irrational treatment and thrive without accountability. Finally, it is characterised by a deep co-option of medical professionals. Doctors’ own hospitals and income are linked to profits. Hospitalisation, prescriptions, tests and procedures, even if unnecessary, are rewarded. There can be no more dangerous conflict of interest for citizens seeking care. Thus, ordinary Indians are caught in a pincer of costly, excessive care in the private sector and crowded, slow, suboptimal care in state facilities.
The situation became embarrassing for political parties. What could they do? The task of reinvigorating the public sector seemed difficult and too long for quick electoral dividends. The next best policy was to buy care from the private sector through mass insurance schemes for the poor. The early starters were Aarogyasri in Andhra Pradesh and Rajiv Gandhi Jeevandayee Arogya Yojana in Maharashtra. Its current national version, the ambitious flagship AB-PMJAY, covers almost half of the population. But for such schemes to be viable, the health sector had to play by some rules and costs had to be rationalised. The growing private health insurance sector also demanded regulation. The Clinical Establishment Act was introduced in 2010 partly as a response to these needs. It seeks to bring a semblance of order by registering all health establishments, setting minimum standards and even rationalising costs by setting ranges. Predictably, it met with resistance. Many state governments have not yet implemented it or done so half-heartedly.
It is naive to think that private healthcare will agree to cost control out of a notion of social responsibility if business is booming anyway. Even during Covid, irrational charging was rampant. It is argued that forcing the private sector is unfair when it is the government’s job to provide healthcare. Whilst this may seem in intuitive its disingenuous because governments subsidise private healthcare in more ways than one. Besides training of health care workers in state institutions, this also includes several infrastructural concessions. In a sense, private health is subsidised by public money.
Previous efforts to control private sector costs have largely failed. The Supreme Court’s intervention is potentially powerful but it is entering tricky territory. Any effective intervention will face resistance not only from industry, but also influential doctors, many of whom are entrepreneurs. If the Court wishes to promote affordable healthcare, capping costs could be a small step. But no nation has improved substantively in health equity without adequate state investment. And India’s state share in health funding continues to be one of the lowest in the world. Can the court address this fundamental issue?
Our nation is in the process of choosing the next government. Manifestos of all parties have made token commitments to healthcare. One would have thought that with Covid in recent memory, the state of healthcare would occupy centre-stage. But politics seems busy with personalities, identity and emotive issues. With the poor internalising suboptimal healthcare as their destiny and the middle class no longer having a stake, activists seek legal remedies to what should be a political battle. Milords, the burden on you is immense, if not unfair.
Nagral is a Mumbai-based surgeon who writes on health policy and ethics
