India’s Private Health Care Delivery: Critique and Remedies

By Sanjeev Kelkar

This book brings together all the major components of the private health care sector in India, with detailed description of its evolution, the foundational ideas, its development, the positives and ill effects on the population. It suggests intelligible and practical remedies for public good. 

The book presents a comprehensive review of private health care sector’s resistance to Indian Government’s reforms like the national medical commission, NEET, clinical establishment act and the new boost to the traditional medicine by the Indian government. The author has discussed contentious areas like Corporate Hospitals, Capitation Fee Colleges, Pharmaceutical Industry, Western Models in Health Care, Integration of Medical Systems, Ayushman Bharat Scheme, Health Insurance and Public Private Partnership on a massive scale.

• Language: English
• Publisher: Palgrave Macmillan
• Release date: Feb 19, 2021
• ISBN: 9789811597787

Book preview

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021

S. KelkarIndia’s Private Health Care Deliveryhttps://doi.org/10.1007/978-981-15-9778-7_1

1. Introduction

Sanjeev Kelkar¹  

(1)

Pune, Maharashtra, India

Keywords

Corporate hospitalsPharmaceutical IndustryNational Medical CommissionFuture ChallengesAyushman Bharat

This volume is about how the private sector caters to India’s health needs.

It starts with the most visible emblem of private health care—corporate hospitals. These have contributed a great deal to the quality and multifaceted growth of medicine in India. However, for reasons of shortsightedness at its roots, it has deteriorated in myriad ways and no longer serves the center of care, the patient. The mechanisms, operations and ill effects it has caused for health care delivery outbalance its positives. Unjustifiable cost escalations, relentless pursuit of money involving exploitation, super-saturation in urban locations, and malpractice for monetary gain have affected the fundamentals of clinical management, which cannot be excused. Along with this, the ethics of the practice are violated, as well as the doctor—patient relationship, followed by a sense of hopelessness and anger among citizens. To rectify the situation there should be a powerful buildup of public health care delivery to answer most questions in a sizable community within short distances. The other remedies needed are discussed in the chapters of this volume.

The second factor which has significantly affected the ‘health’ of health care is the unbridled development of the private or capitation fee medical colleges. The sordid history, false reasoning about its necessity to exist, the immorality of the enterprise and the machinations working therein are unpleasant. This has converted the meritocracy in education to a money market. No one likes the system, not many really know about what happens in these colleges, many connive to gain access to them for the likely benefits that can be purchased in case of need, and some build elaborate facades of shortages of doctors to justify their existence, hiding the ulterior money-making motive. Legal systems defend the tremendous and deep-rooted vested interests and work to keep them intact, resisting any interventions by using the powers invested in them. The sanctity of human life and legal ethics are also violated. In the absence of any justification for the existence of these colleges, a systematic plan for phased elimination is necessary, outlined here in detail.

The world of pharmaceuticals is perceived in different ways by different people: thinkers and activists, the government machinery and those who are working in this industry. Having worked on both sides of the industry, the details of the operations of various interested parties detailed here should give a balanced and real picture. The massively moneyed pharmaceutical industry faces a difficult challenge here—to introspect.

The first of the two chapters devoted to the pharmaceutical industry paints a picture of the achievements of the Indian drug manufacturing industry, now the global center of drug manufacturing The important issue of the quality of the drugs manufactured, the way it is done in the present system in India and what should be done to rectify this is not well understood. Additionally there is a serious deficit in the capacity for drug testing for quality before allowing drugs on the market. The technical, legal, economic, administrative and ethical issues associated with drug approvals, safety and optimization in clinical trials and how these affect the health of the population is another area where understanding is limited. Many other issues plaguing the drug industry and the economic hardships the patients suffer under it are now being addressed by the Draft National Pharmaceutical Policy, 2017. Analysis of this policy will give a clearer picture of the efforts being undertaken to make the situation better.

Among the many issues connected with this policy are imports and the need for price fixation. National Essential List of Medicines is a necessity to achieve it, to make drugs available to the vast non affording population sector at lower prices, rational formulations and weeding out irrationality in manufacture of drugs together acting as a deterrent to profiteering will shed light on this all important aspect of drugs. These measures also have a long-term effect on the economics of the industry. However, in the end it is not a losing game.

Modifications to the patent laws have now produced a level playing field. Its relevance on the backdrop of activist demands for it is explained here. In the globalized world other challenges are thrown up, such as mergers and acquisitions on transnational scale. Some of its basics are discussed with a sense that in the big money game these may be ignored. To manage these enormous operations newer technologies are needed and have been developed, and these are presented here.

The pharmaceutical industry and clinical practice are discussed to further the understanding of clinicians, the final purveyors of the policies and the source of expectations for the betterment of patients. The professionals’ understanding and reorientation of their practices will go a long way to improving the industry and the patient care. Factors such as relevance of a national list of essential medicines, criteria for drug selection before prescribing, prescribing rationally manufactured drugs and the concept of rational therapeutics are needed to build healthy relationships between the industry and doctors.

There is a need to improve the understanding of generic drugs and generic prescriptions among doctors and the patients as well. An in-depth discussion about this and the efforts being undertaken by the government will help to ensure better drugs and better practice at much lower costs. Fixed Dose Combination, FDC drugs, mostly are irrational for all the defenses. The industry defended it with professional support. But it is a travesty of the fundamentals of pharmacology, of the issues of bioavailability in modern medicine on one side and poor outcomes for patients on the other. Hardly any thought has been given to these factors by clinicians and thus a thorough critique of FDCs should be an eye opener for all.

The ability to judge the quality of the evidence produced by the clinical trials, the quality of the trials themselves, the relevance and purpose of trials and properly translating this understanding into practice have to an extent been an Achilles’ heel for clinicians. The details here will give a much better understanding of these matters, rarely discussed in professional forums.

Regulations and regulators have played an unenviable role and caused deterioration in the health sector. The Medical Council of India (MCI) stands accused of many of the ills therein. Despite this, however, every effort is being taken to save MCI from being dissolved. These efforts can be matched with determination to save private medical colleges. This war has become the epitome of the tendencies of Indian medical professionals to oppose anything and everything which may either render them accountable or interfere with their politics or their earnings, be it the MCI, the Clinical Establishment Act, fixed dose combinations being eliminated or, as will be seen, the efforts to mainstream the AYUSH system of medicine. The last of these issues is extensively dealt with in Appendix B in the volume India’s Public Health Care: Policies for Universal Health Care published with this one.

Naturally, the National Medical Commission bill, drafted by Dr Arvind Panagaria, the first and now ex vice chair of NITI Ayog, to overcome most problems existing in the field of regulation and health care quality, is being attacked by the profession. From 2017–2018 until June 2019 this bill was effectively blocked by the lobbies as well as in Parliament. In addition, the sharp contrast in the composition of MCI and NMC has become another bone of contention for the same reasons as MCI dissolution. This is unfortunate. The sincere hope is that it gets passed under the new government of 2019 has now been fulfilled.

However, and luckily, the National Eligibility-Cum-Entrance Test, NEET, and the National Licentiate Examination (NLE) for all medical colleges as a prerequisite for registration and postgraduate entry were implemented in spite of all the virulent opposition they received from many different quarters. This was made possible because the Supreme Court reversed its earlier decisions. Implementation of both has produced many far-reaching welcome effects to an extent not expected or explicitly anticipated in the bill. A reasoned reply has been given to all opposition in this volume.

Attempts to implement the Clinical Establishment Act have received the same opposition by professionals for the same reasons they have for opposing the dissolution of the MCI. Opposition over details within the Act may be different but the motivation is the same. Caste-based reservations in medical education is a chronically sensitive issue. In the last few years many other politically flavored issues and demands have been added and complicated the issue. The commentary on this is likely to spark debates once again, but there is no way we can escape its amicable and reason-based resolution for the good of the reserved castes, people in general and health care.

The mainstream model of curative health care is Western. The invasive and pervasive nature of this model affecting clinical thinking is not sufficiently noted, at least in India, which tends to follow it with implicit faith. It is necessary to at least discuss whether such captivation and submission helps the quality of health care in India. This system is backed strongly by transnational bodies whose words are treated like gospel. There are fault lines not within the model as a science but in the way it is implemented. Rationality and sound clinical reasoning should direct its use. The benefit of its technology, its ways of furthering knowledge and its implementation in practice should be reaped by intelligent perception and reasoning.

The main weapons of this system are the clinical trials, the hegemony of evidence, the protocol and guidelines with which it bombards the average conscientious physician, and its technological dominance. Information technology finally takes the process through in clinical medicine and administration of health care as a whole. It is high time somebody sits up and attempts to analyze what is going on and gauge the rationality of it overall. There are present difficulties and future challenges of IT in the Indian health sector.

Health insurance in the Western model of medicine has its positives and negatives, and it is time these are understood correctly. The recent scheme of Ayushman Bharat (Indians Living Long Life) in the budget speech of the Finance Minister on February 1, 2018 is being propagated and understood as Universal Free Health Care. But in fact it is a scheme funded by the government.

Insurance schemes operating in the health care sector in India over many years are discussed in some detail. Insurance does not seem to have eased the situation as much as expected and the insurance sector in India is small. It is yet to witness its consequences in full measure and it needs to be handled intelligently, trying to avoid these consequences by setting certain limits to its rampant growth.

Public—private partnership has been a desirable element in India’s health care delivery for over five decades now. Its ideational development and the way it has been dealt with both by the government and the private sector is discussed here in detail, showing the reasons why this idea has remained ineffective so far. The chapter discusses the mechanisms through which it should become mature and beneficial to become an effective contributor to the health of the people. There are some fundamental rules which are being overlooked, causing more agony for people.

The chapter on health institutes and voluntary health work describes certain models the private sector may find useful to think about and develop. These could vary for complex disorders of varying nature and frequencies and address them specifically. In addition, it discusses in detail the essential nature, and the conditions to be built in them to come to the level of an Institute which more discerning leaders of health care may find useful to think about and orient their work.

We have all but forgotten the voluntarism in many fields of social life, including health. A new breed called NGOs, or non-governmental organizations, has arisen. Prima facie this is a misnomer as upon closer inspection there are many undesirable elements, most of which are unapparent. This calls for a discussion on this sphere of health activities.

The terms reductionism and holism are bandied around without having a precise idea of what exactly these are and their dichotomous relationship. Some understanding of their relative relevance to the wider conceptual horizon is necessary.

Reductionism and holism are directly related to the notion of integration of the Indian and the Western systems of medicine and health. The term integration is also similarly not well understood in all its dimensions, which makes the discussion on this futuristic and long-range aspect of medicine somewhat haphazard, and it tends to fragment into relatively strong positions among the believers of these systems. An in-depth dissection is necessary. For this to happen, a clear understanding of the bases of these two systems needs elucidation. Effort is required to dissect their different layers, ideas and a more rational understanding of them. The subsequent steps of how to proceed in this direction are outlined in this volume and will be of interest. These will open up work areas for the institutions connected with both systems.

The present position of Ayurvedic education, curriculum and different supports of intellectual nature like textbooks, encyclopedias, understanding of the fundamental texts of Ayurveda called Samhitas mentioned here also will serve as an indicator to the agencies for the road ahead. As difficult as this may be considered, the integration is a message that should be delivered. That there is a definite place for AYUSH graduates in the mainstream health care system cannot be ignored or blindly opposed, as is being done. There are many controversies in this regard which are covered in detail in the other volume published with this one on India’s Public Health Care Delivery: Policies for Universal Care.

Increasingly varied, fragmented among new fields, with newer powerful technologies and greater complexities, health care delivery has ironically become more and more unsatisfactory for any stakeholder, mainly the patient, displaced today as the least important factor. Can it be simplified to her satisfaction? In addition, medicine is embedded in the large and complex matrix of social reality as a whole. Can the practice of medicine also be oriented in this perspective? Some answers may be found in the pages of this and the other volume on public health.

Last of all, irrespective of the field, the government is central to all of this. It plans, sanctions, restricts or frees the system, provides legal backing, and is finally responsible for the outcomes. Every word of this volume is ultimately for the governments to think about in terms of what has been happening and what needs to be done.

It is the work of a lifetime. I hope it receives a thoughtful and unbiased reading.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021

S. KelkarIndia’s Private Health Care Deliveryhttps://doi.org/10.1007/978-981-15-9778-7_2

2. Corporate Hospitals

Sanjeev Kelkar¹  

(1)

Pune, Maharashtra, India

Keywords

Corporate HospitalsMedical technologySuper-specialistsUnreasonable CostsCommunication methods

Private Sector before the Advent of Five Star Hospitals

At the time of independence, India had 13,000 professionals in single, private outpatient clinic practice, composed of MBBS, Licentiate of College of Physicians and Surgeons and Registered Medical Practitioners. The latter two survived until the early 1980s (Duggal and Leena 2005). As early as 1955 a well-qualified surgeon opened the first nursing home of Bangalore. Nursing homes opened and owned by a single specialist started appearing in Mumbai by 1968. Polyclinics with a number of specialists from different branches was the next development in all the capital, metropolitan, and A Class cities. It was convenient for the specialists to offer their services by admitting their patients and availing services of other specialists if needed. This helped the nursing homes to get established.

Such nursing homes were certainly a requirement of urban people. They addressed many needs—proximity of care to the residence and home support available for the patient, which relieved strain on the nursing home. Affordable rates, known and trusted professionals, a fair place to be treated, multiple specialties, negotiability of expenses in good faith and familiarity were the additional reasons for preference for nursing homes. To a considerable extent this prevented the fragmentation of care that was to follow. But the nursing homes were still a small money business.

Barring some of those in larger cities which were quite well organized, the nursing homes in bigger cities as well as smaller towns remained infrastructurally and technologically poor, due to lack of finances, poor paying capacity and fewer patients. The requirement of the more sophisticated equipment was not cost effective due to smaller numbers of serious complications that were easily referable to a medical college, a regular and legitimate referral channel which even the multi-specialty nursing homes chose. In metropolises the additional referral point was the large private/public hospitals. And admittedly such references from rapidly increasing individual nursing homes would be few.

Advancing diagnostics in the late 1970s and early 1980s came to the large private hospitals and the medical colleges in capital cities such as Mumbai and Delhi. By the late 1990s as a direct effect of globalization, privatization and liberalization, India’s economy had started to grow. The so-called Great Newly Rich Middle Class of India had started to emerge, and was soon to become a solid 150-million population. The rapid, sweeping and all-pervasive rise of the corporate health sector, in which the moneyed business class saw huge profits, started emerging in greater numbers compared to the few which started in the mid-1980s. These hospitals brought technology and fueled the rapid rise of super-specialty practices, and soon brought the Indian health care curative capabilities somewhere near a world-class level. All this came at a cost, and unless there was a market ready to utilize this, these shrewd businessmen would not invest their money. It is also thus contended by many that the success of paid care in cities with added technology also prompted and stimulated the idea of the super-specialty or corporate hospitals as the next logical step where profits could be voluminous.

A word about the difference in the five star hospitals against the corporate hospitals will do justice to the latter. Five star hospital culture from the beginning was geared toward making the guest more comfortable, pampered and entertained, and these hospitals charged exorbitant amounts to their rich clientele who did not have serious disorders. Almost all the types of outfits of inpatient care facilities have done this at different levels. There was prestige associated with being admitted and treated at five star hospitals by reputable doctors. In the 1970s and the early 1980s, some of the famous hospitals in Mumbai struck pay dirt when Arabs who expected pampering and did not have serious disorders came to India for enjoyment via health. Germany has this clientele even today. This was the last stage of the deterioration of the five star hospitals.

Advent and Justification of the Super-specialty Corporate Hospitals

India’s first corporate hospital, Apollo Hospital, opened in Chennai, in the mid-1980s, followed by one more in Hyderabad by the same name in 1988. Others such as Breach Candy, Jaslok and Bombay Hospitals existed much earlier but had not been called corporate hospitals. All of them started with the idea of all care under one roof with all the sophisticated technological facilities then available that could be brought to India. It took some years for this defining characteristic of such private hospitals to emerge. The high cost, specialty care, the large number of facilities, the sparkle and the sophistication were some of the features.

A change in the way the medical profession started to look at the patient had set in when the University of Mumbai and the other three metropolitan cities started what is wrongly called the ‘super-specialty postdoctoral degrees.’ Every anatomical or functionally integrated organ system became a specialty in itself. Until then the basic post-MBBS, MD or MS was able to competently handle the whole body, attending to most illnesses. The fragmentation of the human body started, and it was not long after that people in general started deriding this approach. It was only later that patients were avidly submitted to super-specialists.¹

The superb professional expertise combined with technology made available for patient care is a signal service these hospitals have created for the Indian population, for which we should be grateful and indebted. The extra knowledge required for the proper use of the technology leading to the super-specialty practice was logical and justifiable. Corporate hospitals had the greatest use and ability to recruit their services. India gradually developed the numbers with this talent and intelligence to answer to these specialties and serve them. This upgradation allowed Indians to practice sophisticated medicine at almost world-class level and address more problematic health care issues. This is an invaluable service and contribution of the corporate hospitals.

Further Evolution of the Corporate Hospitals

Nothing probably could have been as incongruous regarding our total picture of health and nation as the corporate hospitals, as well as five star hotels. One finds it difficult to imagine that our country had this kind of resources flourishing with money and credentials in the 1980s. One may actually feel happy that an outlet was provided to such money to come in the main stream economy again. But one should not assume that everything is fine with either of these types of hospitals. They face the enormous problem of sustaining their infrastructure as well as the quality of services that are on offer every day. Ultimately, these hospitals do seem to manage this quite well, and this is particularly the case with the corporate hospitals. One should be grateful to them for this sustained quality.

The next sea change that occurred was what used to be called in the late 1980s the ‘Glamour Attraction Dependency Cycle.’ Glamour of what is available and strong attraction to it, enough to create a desire for the facility. In a populous country like India there are always enough people who can avail the sophistication, pay the costs and boast about their experience. This also started driving the lower classes to these hospitals. This is not in any way a derogation of the hospitals themselves. These currents established the corporate hospitals, which were then starting to be called five star hospitals, like the hotels, especially by pro-poor health care activists. But this comparison is not accurate: there is a huge difference between the two. The basic contention was that this was not a model for India, just as the five star hotels were not. But these theorists were only partially correct.

Corporate Hospitals and the Masses

One more consideration was and remains about how to harness these super-styled care hospitals as well as their quality of care in the service of each and every citizen of India in a rational manner, through a dialogue with a win-win intention. This may be a sophisticated, technological, disease-oriented Western model which the corporate hospitals practice. It is, however, necessary to understand that there is a crucial need for it for the general population as well. The issue is whether it should only be available to people in cities who can afford it, without any concern for poverty or affordability. In addition, there is no element of public health activities in these super-structures.

The successive governments should have channeled the work their public system could not handle but a corporate could, under reasonable third-party payment agreements, but they failed to do so for a long period. Policies such as keeping a percentage of the beds free for the poor were created but never followed. Even after the advent of many insurance schemes and the National Rural (and Urban) Mission (NRHM and NUHM) this relationship did not evolve further (NRHM document 2012). Provincial Insurance schemes or Rashtriya Suraksha Bima Yojana (RSBY), that is, the National Health Insurance Scheme, started in 2011, did not make as useful an impact as expected. The reasons for this are described in detail in Chap. 9 on Health Insurance, National Health Protection Scheme, Public—Private Partnership. Referral of poor patients to higher centers like the corporates, approved by the various governments to avail life-saving care, is not pursued by government doctors with any regularity, alacrity or willingness in smaller cities even today. Government doctors aim to enter into an arrangement on their own with the management of the corporates and earn some commission for referring cases.

Since 2014 the central government has been seriously attempting a tie-up between more sophisticated private hospitals to treat poor people by giving predetermined fee for the service. The latest plan in this regard is the Ayushman Bharat National Health Protection Scheme, popularly called ModiCare along the lines of Obamacare, though these two are completely different. These attempts will face difficulties in financial terms of engagement, the most contentious issue. The effects have not yet reached a stage of demonstrably better health care for the vast majority of disadvantaged people, especially in the corporate private health sector. This issue is complex and has many layers of consideration which need a much more detailed account of what is happening. This is discussed in great depth and detail in Chap. 9 on health insurance and public—private partnership in this volume. In this chapter our concern is to give a detailed account of the anatomy and functional aspects of corporate hospitals and the various ways they have changed health care, both positively and negatively.

At the same time there is a contrast. People, whether rich or poor and despite the non-affordability and costs, are resorting to corporate care. They go to there for every minor disease. To prevent such wastage of resources in the form of misutilization or unnecessary utilization we need a capable second-level care facility across the country accessible to everyone in the public health care delivery system. This will give the corporate hospitals breathing space and time to attend to their necessary work. Methods will have to be established to draw upon their strengths and work through third-party payment, bound referral channels and contract services to make sense of these useful systems. This and many other aspects of the above issues have been discussed in several places in this as well as the volume on India’s Public Health Care Delivery: Policies for Universal Health Care, published with this one, in great detail.

Super-specialty Professional Manpower and Corporate Hospitals

The advent of what are erroneously called super-specialties in India started in 1980.² The corporates came only a few years later. Cardiology was the first super-specialty, beginning in Mumbai. Over about 12 years, the majority of the super-specialties were established at All India Institute of Medical Sciences, New Delhi, the Post Graduate Institute of Medical Education & Research in Chandigarh and several other high-class public hospitals. However, this underlined the fact that whatever the discipline anywhere in the country, at any point in time, only a miniscule population was able to approach and could afford these services.

The super-specialists logically demanded higher inputs from the corporate setups. Coronary artery bypass surgery, cardiac surgery for congenital defects and valve damage, dialysis and later kidney transplants led the process, with cutting-edge technology. Doctors are now conducting bone marrow, cardiac and liver transplants. Simultaneously, the phenomenal and extremely useful diagnostic equipment had already arrived on the scene by the mid- to late 1980s, and technologically invasive cardiology was the next effective cutting edge. Suddenly the whole milieu awakened to a large number of complex conditions that could now be tackled more effectively in India. This resulted in the public demanding all kinds of costly care with which medicine was able to save human lives at a high cost per case. Since then on this ratio of high cost to benefit at individual level has not changed and has dominated the medical scene.

Contribution of Corporate Hospitals to the Development of Market Economy

The private sector has also created, probably without a conscious design, a taste for a ‘market economy’ with its positive elements and beneficial aspects. From 1992 onwards we have been recognizing the principle of the market and therefore ‘free adventurous economy’ in our national life. We have opened India for competition, privatization and globalization. Imbibing this major step has flooded our lives with better utilities. Life has also become more thrilling and qualitatively improved. The private sector has ridden the tide and made people aware that if they want something they can obtain it for a price and they should not be asking for it ‘gratis,’ a situation even the people understand.

Some More Redeeming Facts

There is absolutely no doubt or denying that the advancement of highly sophisticated medicine at par with global standards in many places in India is due to the corporate hospitals. This is a culmination of all the efforts over many years by high-achieving individuals. Today the private sector as a rule looks to a more positive role and more daring interventionist practice of its trade. By choice and by force of high-complexity medical conditions, practitioners have not continued with the narrow outlook of a single-person project, but actively think of making it a multi-person project, starting not alone but with an institute in mind. On this point they have again shot forward, leaving behind medical colleges and a large number of government institutes. These are perfectly legitimate attempts to attract their share of medical tourism where they can use their superior talents and treat people from around the world. It brings large amounts of money to them but also to the country. There are many benchmark corporate hospitals of clinical excellence in India in the world class treatment