A HEALING TOUCH FOR HEALTHCARE
In December 2017, we heard from Jayant Singh, whose seven-yearold daughter died of dengue-related complications at a big corporate hospital in Gurugram. Once his allegations on how the hospital tried to buy his silence became public, the local administration, through an inquiry, found the hospital guilty of overbilling, leading to suspension of its blood bank and pharmacy licences. A year after filing an FIR, there is no charge sheet yet and the Medical Council of India refuses to agree with the state’s assessment as to what went wrong. After being stonewalled at every step in his effort to seek justice for his daughter, the grieving father has now moved the Supreme Court of India. As gut-wrenching as his fight for justice is, unfortunately, it is not unique or isolated. The difference is that he has chosen to fight where most give up.
Speaking of the legal justice system as the last resort brings us to Dr Kafeel Khan, who was accused and jailed for the tragedy that occurred in August 2017 at the BRD Hospital in Gorakhpur, where 60 infants died over three nights due to a shortage of oxygen. He was arrested on September 2, 2017, and spent almost seven months in jail until the Allahabad High Court granted bail. He was charged with an attempt to commit culpable homicide, criminal breach of trust and criminal conspiracy. The judge who granted bail adjudicated that the State did not have “sufficient legal evidence to connect” him to the charges. So much for due process and equal justice under law for the seven months he spent in prison.
While these stories make headlines and grab our attention for a few days, the underlying rot in the system on which the delivery of healthcare is built is seldom explained in its totality. These are symptoms of a complex network of corrupt and subversive (of public trust) components that work in tandem with the sole aim of profiteering. Healers or Predators?, edited by Samiran Nundy, Keshav Desiraju and Sanjay Nagral, is the answer to a badly needed scholarly analysis of how we got to where we find ourselves today.
While we embark on a very large exercise to provide access to affordable healthcare as a nation now, it is imperative that we understand how incentives were misaligned, mismanaged and perverted in the past six decades so that we don’t go down a similar path once again.
The first two sections of the book, although very well written, are most challenging to digest because they contain strong opinions and arguments about how our delivery systems became so commoditised and disassociated with the ‘public’ in public health and have become the dominion of the for-profit enterprise. Then it becomes an easier read because the message is conveyed through stories and anecdotes. It is a collection of essays from the best in the business on almost all aspects of healthcare delivery today, with incisive analysis.
The book is also heavy on data and metrics. We learn that 72 per cent of hospitals and 60 per cent of hospital beds are in the private sector, for example. That we spend 50 per cent and 80 per cent, respectively, of our out-of-pocket expenditure in private and public sector on medicines and that one in four episodes of illness in India goes untreated because of financial constraints. We understand how a large section of the current service delivery model was underwritten by the government with taxpayer money with the expectation that these institutions would then return that investment in the form
of subsidised care to the underprivileged but, as with everything else, intentionally designed lack of audit and enforcement processes have turned a blind eye toward this accountability.
This book shows how diagnostics work, why margins at corporate hospitals are as high as 1,700 per cent, as the National Pharmaceutical Pricing Authority study demonstrated, and why more than half of our doctor training facilities are private. The essays on corruption within the Medical Council of India, the Justice Lentin Commission of Inquiry, the Vyapam scam, and the implementation of the Clinical Establishments (Registration and Regulation) Act, 2010, which lacks any provision for grievance redressal, land a severe gut-punch.
For its comprehensive treatment of health systems not just in India but in our neighboring countries, the book does miss a key success story—of how Thailand achieved near universal coverage with its 30 baht (Rs 68) scheme. Lessons on how a well-researched system with strong could deliver near universal care for about $80 (Rs 5,700) per person per year are truly relevant to us.
The key takeaway is that reform of our healthcare delivery system is largely driven by external factors. A combination of NGOs and the judiciary has provided a mechanism to force change where elected representatives have failed.
Unfortunately, using the judiciary to effect change is an arduous and long drawn out process. The judiciary can only provide injunctive relief, i.e., stopping certain things from happening or approving compensation to individuals who were harmed, but a systematic overhaul of the process is not the remit of the courts. Those entrusted with the responsibility to legislate and protect public health have shown no desire or capability to do so. And this will not change until such time where every voter demands accountability. Unfortunately, we think of healthcare service delivery only when we are sick. Until and unless we educate ourselves and demand more from our elected representatives by asking pointed questions as to why it takes six long years to fully implement rules notified in 2012, sadly, not much will change.