Role of Private
Providers in ‘Health Care for All’ by 2022
Draft Note
Anant Phadke
(Background : During the
JSA meeting on 21st-22nd March 2012 in Delhi, one of the
decisions was that as a step towards formulating the JSA position in the
current debate about UHC, I would write a draft of JSA’s position on Role of Private Providers in ‘Health Care for
All’. I had circulated the first draft of this note on 10th April amongst those
of us who were to meet in Delhi
As part of our vision
of Health for All, as JSA, we need to put forth a broad, realistic road map for
achieving the goal of Health Care for All (HCA) to be achieved within say coming10
years from now, i.e. by 2022,. We will
reiterate that in order to achieve the goal of HCA, the Public Health Services
would be the backbone of HCA; for this purpose there will have to be
substantial strengthening and expansion of Public Health Services as well as
it’s enhanced democratization internally and in relation to the people. Private
Providers would be in-sourced when and if necessary and under certain terms,
conditions. Within this basic framework, one of the exercises to be done is to
estimate the number of doctors needed for HCA; to see whether private providers
would have to be in-sourced into the HCA system and further if yes, then to
estimate how many private providers would have to be in-sourced and how.
This current note is
limited to in-sourcing of doctors for urban areas. Similar exercise needs to be
undertaken for doctors needed for HCA in rural areas. This will require taking
into account various specificities of rural health care including the role of
CHWs and other paramedics and of the proposed scheme of Bachelor of Rural Health
Care. [1]
Yes. Some back of the
envelop estimation of number of doctors required for HCA in urban areas will
show this. –
Currently our urban population is about 400
million (33% of the total population of 1200 million). As per the WHO norm of 1
doctor per 1000 population, the requirement for cities is 4 lac doctors. However,
in cities, currently about 10 to 15% of the required doctors are in Public
Health Facilities (PHFs).[3] Thus only
60,000 of the required 400,000 doctors for HCA are currently in urban PHFs.
It has been estimated that in 2020, urban
population would be, 532 million, i.e. estimated 40% of the total estimated
population of 1330 million. For this urban population, about 0.5 million
doctors would be needed for HCA. Ignoring premature deaths and retirement of
the existing about 60,000 doctors currently working in urban PHFs, about 0.44 million
additional doctors would be needed by 2020 if all urban health-care is to be
provided by PHFs. As per MCI, 34,595 students were admitted in the 300 colleges for the
academic year 2009-2010, a good number of them in private medical colleges. The
HLEG has recommended setting up of 187 new medical colleges in backward areas. If
these colleges are set up as per HLEG recommendations and are functional by
2022, these colleges would together produce 0.31 million doctors. However, currently
most of the medical graduates go into private practice. Given this background
and the experience of NRHM in recruiting doctors for PHFs, we can not hope to
increase the number of doctors in urban PHFs from the current about 60,000 as
estimated above, to more than say 120,000 to 150, 000 in coming 10 years.
It is thus not
realistic to expect more 25-30% of the required number of doctors to work in
PHFs in India
Progressive
socialization of in-sourced private providers in the HCA system
These in-sourced
doctors would act as an extension of the Public Health system
by following appropriate guidelines. But for this to occur, the terms
of engagement with the private providers should be so formulated.
Towards this end, guidelines formulated by in the JSA’s draft booklet ‘Towards
People’s Health Plan’ prepared during the National Health Assembly II in Bhopal
(1)
Clearly demarcate the commercial private
commercial sector from the not-for profit and voluntary sector in health care
provision and treat them differentially.
:
(2)
Quality and Cost Regulation of service
delivery and a transparent system of monitoring would have to be in place and
these should be structured such that it can be expanded into a system where all
private and public health facilities are eventually so monitored. The systems
of contracting have to be friendly to such monitoring and have the ability to prevent
inappropriate care and costs.
(3)
That the mechanisms of access to the poor are
clearly defined and there are mechanisms of enforcing its adherence.
(4)
PPPs should supplement and strengthen public
sector but not substitute or weaken existing public health care services.
(5)
Expanding/bringing in investment working for
the public health goals: Which would mean no transfer of assets and resources
from public ownership into private hands.
(6)
Prompt payment with dignity for the private
sector partners so that ethical low budget
proprietary services in smaller towns are favoured;
(7)
Ensuring that efficiency is based on better
management practices and not based on unfair wage structures and compromised
social security benefits, especially for women health care providers like ANMs
and nurses;
(8)
Exclusion of private nursing homes where
government servants are providing services from such a framework – to avoid a
conflict of interests.
Now in the 21st
century, various ingredients of health-care like medical education, production
of medicines, diagnostic equipments, machines, etc have already been
substantially socialized in the sense that nobody can deny that the content has
to be based on scientific norms and not on individual views and interests.
Secondly, private
Providers need to follow the same textbooks and guidelines that doctors in PHFs
have to follow. Under HCA, it can be mandated that private providers too would
have to follow the scientific, Evidence-Based Medicine (EBM) and that they will
have to tune in their clinical practice with the goal and logic of Public
Health. EBM has it’s own limitations and politics. For example, it will take a
long time make all practice of medicine strictly, rigorously scientific; medicine
would and should continue to be both art and science of healing; guidelines are
sought to be influenced by private interests; the framework of EBM can be
‘misused’ to push protocols which favour certain corporate interests ------. To
counter all this is another level of struggle. But in the 21st
century, ‘private interests’ have to progressively loose ground in this field
because of the very nature of modern, socialised clinical and social medicine.
To ensure that the
managerial and technical requirements of regulation are followed adequately and
properly, adequate law, rules, policy and regulatory structure should be in
place before any in-sourcing of private providers takes place. The
Clinical Establishment Act 2010 entails that the Director of Health Services
and the DHOs would be in charge of the regulatory work. However, they are
unable to give justice to their existing work responsibilities – do we expect
that they would be able to perform the additional regulatory responsibilities? Unless an effective, adequate regulatory
structure, like the one suggested by HLEG is mandated, the talk of regulation
would mean only empty words.
Differential
strategy for different sections of the private sector -
To win over the
people to our programme of HCA, apart from
the ordinary citizens who would be the main beneficiaries, we need to rally
round a section of the health care providers in the private sector around the
programme of HCA and to neutralize a section of these providers. For this
purpose we need to have some analysis of the different sections within the
private health care providers.
Private providers in India
1.
Traditional healers of various kinds by and
large are not part of the commodity market of health-care and are part of the
pre-modern relationships
2.
Unqualified providers using allopathic
medicines, AYUSH medicines
3.
Graduates and post-graduates of allopathic
and AYUSH disciplines working in their own clinics as general practitioners or
consultants and who are mostly akin to petty commodity producers
4.
Owners of small and medium hospitals who have
a crucial, role to play in providing health care due to their skills and
expertise in modern medicine. Most of them currently make excess money through
commercial exploitation of patients and also through exploitation of the staff
employed by them.
5.
Trust hospitals, mission hospitals which were
set up by socially motivated doctors, philanthropists, 30-50 years back and
which continue to be genuinely non-profit entities.
6.
Owners, managers of so called Trust Hospitals
especially those set up in last 10 years or so have no role to play in actual
delivery of health care.
7.
Owners of the corporate hospitals are
moneybags who have no role to play in actual delivery of health care.
The first two of
these sections would not be part of the HCA system. Out of all the other sections
of the private providers, those who opt to work for the HCA system and are
selected, would have to follow scientific clinical guidelines, protocols and
will also have to discharge the relevant public health functions. The
regulatory framework should be participatory and would have an element of
self-regulation.[4] (Experience of other countries shows that such
regulation of private providers can be achieved.) Secondly all of them will have to respect, observe
patients’ human rights and should have adequate, just grievance
redressal system. But at the same time we need to have different strategy for
these different layers -
In India UK
Similar is the case
with smaller, medium hospitals. Some of these can be in-sourced into the UHC
system under the condition that they follow overall the logic of the UHC
system. The state can then encourage co-operatives of these small hospitals and
can thereby further undermine their ‘private’ nature.
The ‘Trust
hospitals’ are legally registered as non-profit entities and hence if
sufficient public pressure can be generated, they will have to function as genuinely
non-profit entities, especially because they have generally received public
subsidies in some form or the other. This can be done by pinning them down on their
declared objective in the Trust Deed. Secondly more stringent laws, rules
will have to be formed so that all the aspects of their functioning follow the
overall the logic of the HCA system. The current practice of indulgence in money-making
and yet showing no profits in the balance sheet can not be continued! Secondly
their internal functioning would have to be further democratized- the
doctors and other staff working in these hospitals should have adequate say in
the functioning of these hospitals and their democratic rights should be
respected.
The strategy towards
the corporate
sector would depend upon balance of socio-political forces. Most
of the members of this section would be least amenable to serve social goals.
They are less likely to be part of a genuinely regulated UHC system. In any
case all corporate hospitals will have to be regulated even if all of them
remain outside the UHC system. An unregulated corporate sector would adversely
affect the overall culture in the health care even if it serves only
the rich. Progressive social control over the medico-industrial complex
with internal democratization should be the direction we should advocate.
Actual progress in this direction depends upon level of political pressure that
can be generated towards this end. Overall it is true that comparatively, the
Private health system by it’s very nature, is less amenable to internal
democratization because of the constitutional sanctity to private property. But
good unionization and furthering of democratic culture in the society at large
can curtail to some extent the arbitrary power of the owners vis a vis the
employees.
To summarise,
To achieve ‘Health
Care for All’ in India India
This in-sourcing will
have to be based on appropriate guidelines because of which these in-sourced
doctors would act more as an extension of the Public Health System. They would
be so regulated that they conform to scientific, ethical medicine in tune with
the logic of social medicine while they lead an honourable, comfortable living.
Adequate law, policy, regulatory structure and payment on observance of certain
norms – all this will be required to ensure regulation in practice. The
strategy for different layers amongst private providers would have to be
different.
*************
[1] For
example, the distribution of doctors is likely to continue to be uneven in
urban and rural areas to a certain extent for some years. At the risk of being
accused of employing double standards, we can use separate parameters for urban
and rural areas. This is because there is already substantial involvement of
ASHAs, ANMs and other paramedics in rural health care and we too want to
restrict the role of doctors where it is really needed. Hence for rural areas we can take the
Mudaliar Committee parameter of I doctor for 3500 population. But this can not
be done for urban areas
for which we will follow the WHO norm of 1 doctor per 1000 population.
[2] Though in
this note, by way of example, we have estimated the number doctors needed for
HCA in urban areas, it does not mean that other components of the human power
for HCA, i.e. nurses, technicians, Public Health Managers etc. are not
important.
[3] For example,
Dr. Shyam Ashtekar in his study of Nashik district reports that in Nashik city
with a population of about 1.8 million, in 2011, there were only 241 doctors in
various PHFs including Central and State govt. service, ESIS, municipality.
This is 13.3% of the requirement of1800 doctors for a population of 1.8
million.
[4] Towards
a Regulatory Framework for Private Providers in UHC. Anant Phadke, Abhay Shukla. MFC Bulletin,
February-July 2011. mfcindia.org
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