April 29, 2019

SDG3 has less meaning in India’s private health care without a regulatory authority

 

A woman walks into a well-known franchise hospital in Mumbai. The lump on her right breast has been bothering her for some time. The oncologist chides her for not coming in for a breast exam earlier. The woman assures the doctor that she has been vigilant. “Anyway”, interrupts the oncologist “post the biopsy we need to evaluate options. If the growth is malignant then I suggest you go in for a mastectomy. You won’t take very long to recover, you need to come in for a checkup post the surgery. I don’t suspect at your age that you would be wearing a bikini to miss having a breast.” (The woman was 72). Disheartened, she looks up another oncologist for a second opinion.

 

Getting a second opinion in the realm of private health care reduces the chances of patients losing control of what will happen to their bodies. The second or third opinion was what made the same woman recognize that the hospital had mistakenly diagnosed her with stage 3 instead of Stage 1 cancer. She got a lumpectomy done; the fly was not shot down with a canon. Her treatment cost between the range of seven hundred to nine hundred thousand rupees. She was not insured and it was too late for her to get any.

 

 

Her account adds to a plethora of news stories where private health care has failed. In 2015, a case which created major headlines was the death of seven-year-old girl from dengue in a private hospital In Delhi due to hospital facility negligence.  Her family was charged Rs. 15,00000 for her treatment. An amount which was grossly higher than what would be needed for the treatment of dengue.

 

 

Accounts like these are the elephant in the room. Everyone knows about patient negligence in private health care and no appropriate measures are being enacted to prevent it. Yet people go to private hospitals as it is commonly believed wait times are less, chances of hospital related infections are virtually nil and doctors know what they are doing. These perceptions constitute the definition of quality. But in the realm of SDGs, does this definition carry enough weight?

 

 

As we stand, a major target in SDG 3 is the following. “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

 

Yet the notions of the words “safe, effective, quality and affordable” get obfuscated in the complex, tangled web of private health care in India.

 

 

There is very little information on how prices for hospital related services are decided and there are no appropriate regulation mechanisms to oversee whether the type and number of services contributing to an individual patient’s health is based on monetary targets the hospitals need to achieve or on actual need. In numerous cases, patients are kept more days than necessary in hospital or are prescribed unnecessary or incorrect tests and medication. Hospitals know that insurance in most cases will cover costs. This leaves out the 60% of patients who have no health insurance. When they visit a private hospital, they are effectively paying out of their own pocket for exorbitantly priced treatment framed by health care incentives.

 

The concern is heightened as India’s economy grows. The increase in disposable incomes implies a demographic shift from poorly equipped public hospitals to private health care providers. Proper standards of healthcare services and accurate prices needs to exist for the SDG3’s target to have any meaning in the Indian context.

 

 

This article suggests three measures to ensure complaint health care standards – open access to data on justifications for price setting, periodic and independent investigations on compliant health care which are open access and a regulatory authority consisting of stakeholders that are incentivised by compliance and transparency in health care standards and price setting.

 

 

The need for a regulatory authority is imperative given the obstacles presented by the Consumer Protection Act 1986. The Act can be used to sue health care providers for malpractice. The Act is mainly concerned with “medical negligence (which) arises from an act or omission by a medical practitioner, which no reasonably competent and careful practitioner would have committed. What is expected of a medical practitioner is ‘reasonably skilful behaviour’ adopting the ‘ordinary skills’ and practices of the profession with ‘ordinary care‘. At present, patients need to legally prove that the doctor performed below the ordinary skill level . This requires having access to relevant medical knowledge and is a difficult obstacle to overcome. Moreover it would take years for any justice to occur given the over-burdened legal system in India.

 

 

Such a regulatory authority should have the competence to exercise the measures suggested in this article. The regulators could have stakeholders that include members from the medical profession, lawyers and people from insurance companies and health activists. The incentives that guide these stakeholders need to be explored further and is material for another article. This body should have the competence to evaluate complaints against private healthcare and accurately judge the need for medical procedures. It also has the authority to collect data on how prices are set among health care providers and to make this publicly available for patients to make informed choices. It should also enlist the help of independent and periodic studies on health care compliance to inform its work.

 

 

After all, the targets in SDG3 would carry greater weight, if patients didn’t have to rely on doctors or healthcare providers who are regulated by informal relationships guided by friendship or family or second opinions.  The need for better health care compliance is a pressing and growing need.

 

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About Navika Harshe

Navika Harshe

Navika Harshe is a consultant to the Bill and Melinda Gates Foundation through the Liverpool School of Tropical Medicine. She works in the Measurement Learning and Evaluation team. Prior to this she was Senior Manager, Research and Program Management at Operation ASHA. Navika was a Fulbright Scholar at the University of Chicago where she received her Masters in Public Policy. She also holds a Masters in Economics from the University of Hyderabad. Prior to joining Operation ASHA she worked with the federal government of India in both the Parliament and the Planning Commission. Her research interests include Health policy and its implementation, Economic development, Social and Public policy and Education policy.

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About Azania Thomas

Azania Thomas

Azania Thomas has had an interesting journey in international development. In 2005, she completed an MA in Economics, completed a teaching certification (CELTA) and worked as a PR and Capacity Development executive for an NGO in Mumbai . In 2007, she moved to Mexico City, where she worked as an English language teacher and Economics Lecturer for 5 years. She felt her work would have more meaning for marginalised populations in developing countries. She returned to India and began work as a training consultant for the British Council’s education programmes in 2012. In 2013-2014, she studied at the University of Edinburgh, where she completed an Msc in South Asia and International Development. Since 2016, she have been working as an education consultant for a number of British Council projects. Lately, she has had a growing interest in issues affecting health care in India and is exploring connections between skill development and healthcare. When she is not spending her time engaged with issues in the international development world, Azania spends her time painting and developing her fine art collection.

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