Monday, August 23, 2010

India's complex healthcare system - Chap 3 from Dr Nadkarni's book

The Health Care Delivery System is equally complex. The main method of health care delivery was through private medical practice. The patient directly went to the doctor. He, in turn, established his own clinic or nursing home or hospital. The relationship between the doctor and the patient was direct. The fees charged by the doctor, therefore, were also totally unregulated and depended on the whims and fancies of the practising doctors or on general market value.

Slowly institutional system of health care got established. The government both central and state as well as some public sector organizations like railways started establishing their own health care services. This was the beginning of secondary health-care service. Most of these health care services in public sectors treated the patients free of charge and the doctors working there were paid some fixed remuneration as per the quality of service they gave. Similarly hospitals or health-care systems were established also by many big corporates like Tata Streel, They also employed the medical practitioners at a fixed salary and treated the patients from their own institution free of charge.

The growth of private sector in many other fields made entrepreneurs realize that health-care is also an industry and this resulted in establishment of many corporate hospitals and many trust hospitals. These are run more professionally. The hospitals provide more and more facilities in the form of modern equipments and employ the doctors to serve the patients coming to the hospital. However, the treatment is not free and the patients have to pay for every service they get. In order to strike a balance between the capacity of the patient to pay and actual charges, the patients in these hospitals are classified as per their financial status and the charges are graded accordingly. The doctors working in such hospitals are not on fixed salary but get their charges as per the patient they treat and the services they render, in the class the patient has chosen. More the patients, more the income. More the patients in upper class, more the income. Though some of these new hospitals are now restraining their doctors from practicing outside in the private fields, as yet majority of these doctors are free to practice privately in addition to their attachment at these hospitals.

Religious institutions are playing a substantial role in the health-care delivery system. Christian missions have established many secondary hospitals, but strangely they have contributed so little to primary health care. Nowadays plenty of Hindu and other religious bodies have entered in great numbers to establish similar secondary hospitals. The treatment offered here is free or highly subsidized and there is an admixture of paid doctors on fixed salaries and honorary doctors who get paid, like in private and private charitable hospitals, but usually on a lower scale. As mentioned, very few of them have dared to enter the field of primary health-care. When a patient suffers a high-risk-illness and therefore goes to a tertiary medical centre, he is treated by super-specialists but, strangely, he meets his doctor less and less. Higher the risk of his illness, more he loses contact with his doctor. He is seen by junior assistants appointed in the hospital. In fact, there could be another strata of junior specialists who mainly look after him. Thus, he is able to meet his super- specialist only briefly and if would not be surprising, if the patient meets his super-specialist at the time of the procedure only. This happens too frequently in public sector but it is also the experience of those who enter major tertiary care charitable or private hospitals. The only exception is small, secondary care private hospitals and nursing homes where the patients most often meet and deal directly with the specialists. That is why these hospitals are most popular among the middle-class population.

Thus, though the private sector has entered the field of health-care in a big way now a days, the entry is restricted to secondary health-care and even more significantly in the tertiary health care. General physicians in private practice form the bulk of the private sector participation in primary health–care, but with the majority of qualified allopathic doctors choosing to go for specialization this private sector has fallen into the hands of non- allopathic doctors, who nevertheless practise allopathy. The primary health-care-remains neglected, even in the private sector.

A vast majority of rurual and semi-urban population depends on public sector for their primary health-care needs. It least 60% of the total population of the country could be served by the state i.e. central & state governments, municipalities, jilha- parishads and gram-panchayats. For them, the state has created a network of primary health-centres with their subsidiaries while municipalities have created their dispensaries in the cities. The treatment in all these centres is supposedly free; but inefficient and corrupt administration makes most of the patients to spend huge amount for their treatment. In addition the facilities provided are very meagre and the pay-structure of the employed health-care professionals is also very poor. Unattractive pay and unattractive service conditions can not attract good talents, and those who serve in these places constantly look for better opportunities and leave the job within a few years or become corrupt or are of hopelessly low calibre. Thus, the vast majority of the population in the country have a poor primary health-care service available to them both in public and private sector. For further care, the state has also established secondary care hospitals at Taluka and District places, while Medical College hospitals are probably the only centres offering tertiary care in the public sector, barring a few exceptions.

Another system was introduced in the form of Employees State Insurance Scheme, only for industrial labour with low income. The industrial labour contributed 1/3, the owners contributed 1/3 and the government contributed 1/3, to make the total budget. Services were established with the object of giving total health care to labourers and doctors were employed to work as general practioners or in the hospitals specially created under E.S.I. Scheme. For primary health care, the doctors were employed as general practitioners and the patients were entitled to choose their doctor and submit their health cards to the doctor of their choice. The doctors were thus entitled to a payment proportionate to the number of cards each of them held. If he was popular and many labourers chose him, naturally he would get more payment and vice versa. These doctors were not supposed to practice in the private field. However, the renumeration given was so low and the administrative set up was also so poor that most of these doctors freely practiced as private practitioners and most of the labourers went to the doctor not so much for the treatment but for getting certificate of illness to take maximum advantage of the personal benefits offered by the company. Despite huge amount of money lying with the scheme, the employees state Insurance has become a great flop.

I have tried to point out that the health-care delivery system is also not well defined and different systems are working at the same time in the same city or district. The rules governing the role of each doctor in each of the systems is extremely ill defined or even if the role is defined by the rules, these rules are not followed at all and any doctor from any system or any specialty freely wanders into the territory of others in order to make money and yet goes scot free. No action is possible as company /government rules are so flimsy, and medical councils have framed no rules in this matter.

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