History shows that where ethics and economics come in conflict, victory is always with economics. Vested interests have never been known to have willingly divested themselves, unless there was sufficient force to compel them.

– Dr. B.R. Ambedkar

LET us begin with two real life experiences. Experience one: A friend aged 32 years, had her first delivery in a National Health Service facility in the UK. It was a normal delivery and she was discharged within three days. The day after, a nurse and woman attendant visited her to check up on how she was doing and continued these visits for the next five days, and the attendant continued visiting for another week. The family did not have to pay a single penny for the entire care.

Experience two: In the metropolis of Mumbai, a 35 years old woman pregnant for the first time, was registered with a private gynaecologist. Upon getting labour pains, the houseman admitted her at 10.30 am while assuring that the gynaecologist would come soon. The long-awaited gynaecologist finally landed up at 8.45 pm, after a long journey directly to the hospital. After this huge delay resulting in major complications, the mother delivered a baby with severe brain damage. Besides huge expenses for NICU admission, the mother had to sacrifice her job to take care of the child, who is now mentally retarded for life.

These two experiences represent a contrast between different healthcare systems; the first from a universal healthcare system where healthcare is mostly removed from market forces, the second being a product of unregulated healthcare left to the market. It is the system which mainly determines whether healthcare will be ethical or unethical.

Ethics in healthcare is not just about ethical behaviour of individual doctors, which is mainly the result, not the primary cause related to how the system functions. When profiteering embedded in an unregulated market drives healthcare provisioning, negligence, malpractices and exploitation of patients become the norm, while doctors working ethically become exceptions. On the other hand, in a publicly organized system where provisioning of healthcare is removed from market forces, profit-making is majorly controlled, with no perverse incentives to subvert quality or financially exploit patients. Unethical practices become exceptions and are likely to be corrected by the system. Hence the widespread lack of ethics in private healthcare in India today, needs to be understood in the context of its commercialization over the last three decades. The culpability of a large section of medical professionals in this process, as willing accomplices, is not denied. We need to, however, prioritize causation and contextualize it within the setting of political economy.

 

In the last four decades, the Indian government has moved away from its commitment to the Alma Ata Declaration (1978),¹ which proclaimed health as a human right and emphasized the central role of the state in providing adequate health and social measures to attain this goal. The second half of the1980s initiated unregulated expansion of profit-driven private healthcare in India, a process of commercialization that has continued until today with the active or tacit support from successive governments.

‘Commercialization’ of healthcare has been defined as:² (i) the increasing provision of healthcare services through market relationships to those able to pay; (ii) the associated investment in, and production of those services for, the purpose of cash income or profit; and (iii) an increase in the extent to which healthcare finance is derived from payment systems based in individual payment or private insurance. Commercialization thus encompasses and provides a single framework of analysis for understanding a number of intersecting processes such as private sector expansion, market liberalization and privatization of state assets.³

In the Indian context, this process can be understood by assessing the shift in the proportion of healthcare provided by public vs. private healthcare sectors. During the eighties, 60% of inpatient care was provided by the public health system, while the private sector (then mostly nursing homes and charitable hospitals) catered to 40%. Now according to NSS data 71st round (2014), the private sector has become the dominant player, accounting for 58% of rural and 68% of urban hospitalizations at all-India level.⁴ Within three decades, the private healthcare sector has moved from secondary position to becoming the major provider of healthcare.

 

The neo-liberal policy framework implemented since 1991, has shaped this rise and rise of unregulated private healthcare in India. The process received a further boost in 2000, when the Government of India allowed 100% direct foreign investment (FDI) in the hospital sector. The National Health Policy 2002 stated that it ‘welcomes the participation of the private sector in all areas of health activities – primary, secondary or tertiary.’ The 2003 national budget accorded healthcare the status of an industry, following which long-term cheap loans were granted to private healthcare institutions.⁵ The ongoing commercialization has been accelerated by a range of drivers, promoting the penetration of profit-maximizing capital in various segments of the healthcare sector, as briefly mentioned in the following paragraphs.

India has the largest number of medical colleges in the world, with 242 government medical colleges (33,160 seats) and 254 private medical colleges (27,370 MBBS seats). In Maharashtra alone, there are 23 government medical colleges with 3210 seats and 28 private medical colleges with 3620 seats.⁶ The growing preponderance of private medical colleges is explained by the fact that 72% of the seats added after 1972 are in the private sector.⁷ Here the astronomical fees charged by many private medical colleges is a matter of huge concern. In a private university based in Navi Mumbai, the fees for the MBBS course are Rs 16 lakh per year (amounting to over Rs 80 lakh for the full course).⁸ For postgraduate enrolment in branches like radiology, allocation of seats may be based on competitive bidding, with the amounts paid being upto four crore.⁹

Such private medical college ‘factories’ are churning out tens of thousands of doctors annually whose primary ‘merit’ is the ability to pay, and logically the uppermost objective of most such doctors is reaping super-profits to recoup the investments made. This often implies unnecessary medication, investigations, admissions and operations to boost the ‘bottom line’. Undoubtedly, the private medical education ‘industry’ is a core driver for commercialization of healthcare.

 

Governments in India have offered generous financial concessions to corporate hospitals in the form of subsidized land, reduced import duties, and tax concessions for medical research/education.¹⁰ Added to chains of corporate hospitals, are corporate owned laboratories and radiology facilities. Multinational funds are being poured into the Indian healthcare sector with an eye on high returns on investment; the Apollo chain is 45% owned by foreign investors while Fortis healthcare is set to be acquired by IHH Healthcare Malaysia. Narayana Health has a major investment by JP Morgan and CDC Health with veto powers and so is now effectively ‘foreign controlled’. In 2015 US based Carlyle Group acquired a 37% stake in Metropolis Healthcare pathology laboratories. Columbia Asia and Da Vita (US), Fresenius (Germany), Sakra Hospitals (Japan), Abraaj (Dubai) are other major internationals which are investing in a major way in the Indian healthcare sector.¹¹

Such eagerness of corporate investors, whose overriding objective is maximization of profits, is not surprising since the profit margins to be made are unimaginably high. For example, Apax partners invested in Apollo Hospitals and tripled their investment within six years (2007-2013), while Avenue capital invested in Medanta and in seven years multiplied their investment by four times (2006-13).¹²

 

Globally, the Indian pharmaceutical sector ranks third in terms of volume of production, valued at US$ 33 billion in 2017. This industry is expected to expand at a CAGR of 22.4% over 2015-20 to reach US$ 55 billion;¹³ these major profits being often extracted through sale of overpriced formulations. The private pharma industry has a free run in making profits, being riddled with irrational fixed combinations and expensive ‘me-too’ formulations, with very poor (mostly advisory) regulation. Hundreds of brands for each medication, many of which are grossly overpriced, compete with each other. This has spawned a massive sub-industry of ‘medical marketing’ wherein competing companies aggressively bribe doctors, inducing them to prescribe specific brands that are generally more expensive and less rational.

 

India has a flourishing private medical device industry that includes diagnostic imaging products, consumables, orthopaedic implants and prostheses. During the period between April 2000 and March 2017, USD 1.57 billion worth FDI flowed into this sector.¹⁴ The Indian medical device market is expected to expand to approximately US $4.8 billion by 2019. As part of the private healthcare sector, the medical device industry also is weakly regulated. The recent episode of multinational company, Johnson and Johnson, going scot free without paying compensation, after selling thousands of faulty hip replacement implants, is a glaring example of massive regulatory deficits and institutional violation of medical ethics.¹⁵

In addition to these drivers, commercial medical insurance companies and the globalized vaccine industry are also contributing to commercialization of healthcare in India. The Indian masala added to this globalized concoction is a lack of effective regulation on most fronts with the government supporting unchecked expansion of private healthcare as an ‘engine of growth’, as mentioned in a report of the Planning Commission in 2012.¹⁶

 

With profit maximization overriding the logic of rational medicine, widespread ethical distortions of healthcare in India are painfully visible. These have been documented in Dissenting Diagnosis¹⁷, a book written jointly by the authors of this article with interviews of 78 whistle-blower doctors from across India sharing striking instances of unethical practices from their personal experience. For example: ‘Every week I come across 2-3 elderly persons who actually just need spectacles but have been told to get operated for cataract. Those who have insurance fall into the trap and go in for the surgery.’ (Ophthalmologist, Metro City)

According to a senior cardiologist, as per standard treatment guidelines, the percentage of patients requiring admission for procedures as a proportion of all outpatients (conversion rate) is around 15%. However, the corporate hospitals’ conversion rates range upto 40%. Cardiologists are forced to advise around 25% of their patients to undergo completely unnecessary angioplasties/bypass operations, violating the health needs of the patient but boosting the ‘financial health’ of the corporate hospital.

Similarly, the rate of C-sections in India is more than three times higher in private hospitals (41%), as compared to public hospitals (11.9%).¹⁸ Breaching the WHO norm of 10-15% deliveries requiring a caesarean operation, in several states the rate is alarmingly high with Telangana (74.9%) having the highest number of C-section deliveries in private hospitals.¹⁹ Mothers from the highest wealth quintile are nine times more likely to deliver through C-section (36%) than mothers in households in the lowest wealth quintile (4%)!

There is also ample evidence illustrating unethical marketing by pharmaceutical companies: ‘Three neurologists had been sent on a foreign tour by the company, and to entertain them they have sponsored two South Indian heroines just to entertain those three doctors; it is really pathetic to see that pharma industry has gone to this abysmal level of marketing.’ (Informant from pharma industry in an interview to SATHI, for its ongoing study on promotional practices of pharma companies.)

 

The systemic violations of medical ethics are perpetuated in a setting of failed or captured regulation of the private healthcare sector. The Medical Council of India, a self-regulatory arm of the medical profession, is itself ridden with deep-seated corruption. The 92nd Joint Parliamentary Committee observed: ‘It is a matter of surprise that despite the worst kind of gross unethical practices happening by way of ghost faculty, fake patients and hired instruments and substantial amount of money (not white, of course) reportedly changing hands at the time of inspections, there is little proactive action on the part of the MCI to deal with this malady.’²⁰.However, the alternative being proposed – a National Medical Commission – has been plagued by multiple controversies even before being formed.²¹

Until 2010, various Indian states had only nominal acts in place to regulate the private healthcare sector, mostly limited to registration. Then the central government passed the Clinical Establishments Act (CEA) which was a definite step forward.²² However, since hospitals and dispensaries are a state subject, each state government has the option of either adopting the central act or passing its own regulatory act. Till date 11 states and all union territories have adopted the central CEA, yet the standards accompanying the act are yet to be notified, effectively preventing the act from being implemented. Resistance by private medical lobbies and apathy at government level have ensured that 70 years after Independence, there is no effective regulation of the quality, rationality and costs of care provided by the private healthcare sector in India.

 

Public action to overcome private sector failure²³ has yet to emerge. Nobel prize winning economist Kenneth Arrow had warned over half a century ago²⁴ that in the realm of healthcare, competitive markets generate inefficient allocation of resources leading to market failures; in India today we have not just market failure but a market disaster. The time has come to roll back these widespread market failures, products of an unregulated, profit-driven private healthcare industry, through large-scale public action which would be centred on establishing healthcare as a basic human right.

Over last two decades, national networks like Jan Swasthya Abhiyan²⁵ and Medico Friends Circle²⁶ have done considerable work towards outlining a comprehensive programme of change for the health sector. Here we will focus on a few examples of emerging positive initiatives and concepts, which offer hope in the current challenging situation.

 

The Alliance of Doctors for Ethical Healthcare (ADEH)²⁷ responded to the need felt by a small but significant section of doctors to come together for promoting reform from within the community. Formed in 2016 following publication of ‘Dissenting Diagnosis’, over two hundred doctors from across India have joined hands to promote ethical and rational healthcare. ADEH has demanded reform and restructuring of the Medical Council of India, provided inputs to the National Pharmaceutical Pricing Authority (NPPA) towards fixing prices of coronary stents and devices, and is formulating proposals for capping of trade margins in consumables, implants and medicines.

Likewise, citizen-doctor forums initiated by active citizens, civil society activists and reform oriented doctors are aiming to move beyond adversarial ‘patients vs. doctors’ type positions. Mumbai Citizen Doctor Forum provides support to patients who have suffered from serious medical malpractices, while demanding reforms in bodies like the Maharashtra Medical Council to redress patient grievances. Similarly, the Pune Citizen Doctors Forum (PCDF)²⁸ has developed a web-based platform which patients can use to share information on doctors found to be patient-friendly.

 

Keeping in view popular demands to protect patients’ rights in private hospitals, related charters have been developed such as the Joint Charter of Patients’ Rights and Responsibilities formulated by Jan Arogya Abhiyan through discussion with the Indian Medical Association, Pune, in 2010.²⁹ This was followed by further efforts, culminating in the National Human Rights Commission of India formulating a comprehensive 17-point Patients Rights Charter in 2018, on which comments have now been invited by the Union Health Ministry³⁰ as a prelude to officially implementing this in context of all healthcare establishments, private as well as public. This charter will enable patients to demand accountability of private hospitals related to violations which are currently widespread.

If we proceed from the view that regulation is a form of social accountability, then regulation needs to be re-imagined: ‘…patients’ and citizen’s concerns must be strongly reflected in a regulatory framework, otherwise regulatory bodies might be captured by elites, or may become an additional channel for corruption. In this context … social regulation would have three interrelated components: state regulatory bodies, multi-stakeholder oversight and monitoring committees, and technical committees consisting of diverse medical professionals. State regulation would be based on legal frameworks, executive authorities, grievance redressal mechanisms and inspectors. Multi-stakeholder accountability and oversight bodies including civil society and patients’ groups, as well as representatives from the medical profession would monitor the regulatory and grievance redressal processes.’³¹

Such initiatives and frameworks can help society to tame the mammoth of private healthcare in India. However, the most crucial direction required for checking exploitative practices of private healthcare sector is massive strengthening and expansion of the public healthcare sector, while ensuring its accountability and responsiveness to communities. Such rejuvenation of public health services, and effective, accountable regulation while harnessing private healthcare providers can form the basis for moving towards a publicly organized and funded system of universal healthcare (not ‘coverage’) in India.

 

Only such systemic change can eliminate commercialization of healthcare and the undermining of medical ethics. As a society we need to make a choice regarding the kind of health system we want in India – whether healthcare should remain a commodity to be purchased only by those who can afford it, or a human right to be enjoyed by all.

 

Footnotes:

1. https://www.who.int/social_determinants/tools/multimedia/alma_ata/en/

2. Maureen Mackintosh, HealthCare Commercialization and the Embedding of Inequality – RUIG/UNRISD Health Project Synthesis Paper, Geneva, 2003.

3. Maureen Mackintosh and Meri Koivusalo, UNRISD Policy Brief: Commercialization and Globalization of Health Care: Lessons from UNRISD Research. Geneva, 2007.

4. http://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdf

5. Shah and Mohanty, 2011.

6. https://www.mciindia.org/CMS/information-desk/college-and-course-search

7. A. Supe, W.P. Burdick, ‘Challenges and Issues in Medical Education in India’, Academic Medicine 81, 2006, pp. 1076-80.

8. Personal communication by a faculty member of a private medical college based in Navi Mumbai.

9. https://timesofindia.indiatimes.com/city/mumbai/pvt-med-colleges-step-out-of-pg-ad-mission-process/articleshow/63323223.cms

10. R.V. Baru, ‘Privatization and Cor-poratization’, Seminar 489, May 2000. Available from: http://www.india-seminar.com/2000/489/489percent20baru. htm. [Last accessed on 30 April 2012].

11. Indira Chakravarthi et. al., ‘Investing in Health: Healthcare Industry in India’, Economic and Political Weekly 52(45), 11 November 2017.

12. Ibid.

13. https://www.ibef.org/industry/pharmaceutical-india.aspx

14. http://dipp.nic.in/English/Publications/FDI_Statistics/2017/FDI_FactSheet_ January_March2017.pdf

15. https://indianexpress.com/article/opinion/columns/johnson-and-johnson-faulty-hip-replacement-surgery-jp-nada-medical-negligence-5331648/

16. http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol2.pdf

17. https://www.amazon.in/Dissenting-Diagnosis-Arun-Gadre/dp/8184007019

18. International Institute for Population Sciences (IIPS) and ICF, 2017, National Family Health Survey (NFHS-4), 2015-16: India. IIPS, Mumbai.

19. Shweta Marathe and Renuka Mukadam, ‘Profiteering Hospitals are Driving Alarming Rise in C-Section Deliveries in India’, The Wire, 21 April 2017. https://thewire.in/health/c-sections-health-women-pregnancy

20. Joint Parliamentary Committee on Health, 92nd Report – recommendations, p. 102.

21. http://niti.gov.in/writereaddata/files/document_publication/MCI%20Bill% 20Final.pdf

22. http://clinicalestablishments.gov.in/cms/Home.aspx

23. This section has substantially drawn upon sections of the article by Abhay Shukla, Abhijit More and Shweta Marathe, ‘Making Private Health Care Accountable: Mobilising Civil Society and Ethical Doctors in India’, IDS Bulletin 49(2), March 2018.

24. Kenneth Arrow, ‘Uncertainty and Welfare Economics of Medical Care’, The American Economic Review 53(5), December 1963.

25. Jan Swasthya Abhiyan, Universalizing Health Care for All. November 2012, Delhi.

http://phmindia.org/wp-content/uploads/2015/09/universalising-health-care-for-all.pdf

26. Articles in MFC Bulletin esp. www. mfcindia.org/mfcpdfs/MFC342-344.pdf; Also see www.mfcindia.org/mfcpdfs/2011-.html

27. www.ethicaldoctors.org

28. www.mypcdf.org

29. ‘Docs, NGOs Join Hands to Ensure Patients’ Rights’, Times of India (Pune), 10 February 2010. https://timesofindia. indiatimes. com/city/pune/Docs-NGOs-join-hands-to-ensure-patients-rights/articleshow/5553778.cms

30. https://mohfw.gov.in/newshighlights/draft-patient-charter-prepared-national-human-rights-commission

31. Abhay Shukla, Abhijit More and Shweta Marathe, March 2018, op. cit.