PRIVATE HEALTH SECTOR IN INDIA (Annotated Bibliography)
Introduction
Private health sector which supplements public health facilities is very diverse, besides the inequities, questions and concerns include practice by quacks, unethical practices, substandard facilities, lack of regulations, medical malpractices and negligence, unnecessary procedures and surgeries etc.
CEHAT, over the last decade has been advocating for improvement of private health sector in terms of quality, standards and regulation. Emphasising state's role in providing good quality health care, CEHAT's study on accreditation suggested establishing an accreditation body. This body should include various stakeholders. Hospital owners and administrators, participated in the study, felt the need for an accreditation body because of (i) the increased competition in the health sector (ii) no advantage enjoyed by hospitals maintaining certain standards (iii) the realisation that standards needs to be improved and updated and (iv) the emergence of health insurance. Providers and consumer organisations, participated in the study, also agreed on the formation of an accreditation body. In addition Government's involvement would also be of importance in legitimising the body. The body will ensure quality health care through,
- assessing hospitals for compliance to set standards,
- providing assistance to hospitals to upgrade their standards,
- ensuring proper patient care, and
- aiding to upgrade standards of hospitals through education, training and consultation.
Accredited hospitals need to be monitored for standards, quality, price and consumer satisfaction. Issues that relate to accreditation body are of functioning, periodicity of assessment procedures and financing.
This research study led to a workshop aimed at establishing an accreditation body. Participants of the workshop - various stakeholders, discussed the need and credibility of such a body and felt its importance in ensuring quality health care in the private health sector. An ad-hoc committee named Forum for Healthcare Standards (FHS) convened by CEHAT was also formed. The Forum focuses on developing standards for hospitals, wards, labour rooms, operation theatre, essential drugs, waiting area or reception room, consulting room, changing room, pantry, medical records and waste management and different specialities and super specialities. In addition, CEHAT prepared a framework for the accreditation body as well.
Earlier CEHAT had proposed certain minimum standards for the private health sector from a study in Maharashtra. It lists out minimum standards for nursing homes that provide medical, surgical and maternity facilities and explains standards in various components to integrate nursing homes to the community. It narrates the way of setting up a functional programme that describes the purpose of the nursing home, its projected demand for utilisation, staffing pattern, departmental relationships, space requirements and other basic information.
On the issue of regulation of the private health sector CEHAT contributed to the amendment of the Bombay Nursing Home Registration (BNHRA) Act, 1949. CEHAT collaborate with Jan Swasthya Abhiyan (JSA / PHA), Health Care Accreditation Council (HCAC) and Forum for Medical Ethics Society (FMES), towards advocating for passing the Act with certain modifications. A researcher from CEHAT (in his personal capacity) contributed to the drafting of amendment while CEHAT, in its institutional capacity, participated in a stakeholder workshop organized by the Government of Maharashtra.
This Health Panorama is a compilation of the major researches conducted by CEHAT and others on private health sector. Highlights of a few research reports are also included. The panorama starts with an overview of privatisation in medical care in the Indian context. Baru overviews the emergence of various forms of health care on a global basis, citing cases of various developed and developing countries. It was during the last decade, privatisation gained a central place in determining directions in health policy the world over. In India, the private sector has grown and its distribution is skewed towards urban areas and concentrated in some states. Private interests in health have grown over the years and a significant proportion of doctors are employed in the private sector and there has been a growth of private nursing homes and hospitals since mid seventies.
Followed by the overview is Nandraj's critique titled 'Beyond the Law and the Lord: Quality of Private Health Care'. He points out the low regard given to quality aspects by the private health sector. Among the practitioners, quacks form a great majority. They are mainly those who served as helpers, pharmacists or assistants to doctors for a period of time. Sometimes spouses of doctors are also included, who sit in the clinic in the absence of the doctor. Sons or daughters who 'inherit' the practice of their parents also practice medicine illegally. The attention was paid on the functioning and quality of care by private practitioners because of the cases of medical malpractice and negligence filed in the court of law by the victims and their relatives as well as due to the role-played by media and different consumer organisations.
Nandraj and Duggal's research on physical standards in private health sector is empirical and at the same time policy relevant. They attribute rampant, unregulated, unplanned and largely unmonitored growth of the private health sector as the cause of the current situation of poor and unreliable quality of care. Authors suggested the following actions as a step to reform in this sector (i) make people aware of their rights and duties in the health care system (ii) state and medical councils should ensure that only properly qualified persons practice (iii) through licensing and encouragement, government should ensure proper geographic distribution of practitioners and hospitals in the country (iv) regularise medical prescription audits and mandate renewal of license and registration on it and (v) maintain proper records and provide access to patients as well.
Related to quality and standards is the issue of regulation. Duggal and Nandraj's paper titiled 'Regulating the Private Health Sector' reviews the tremendous growth of private health sector in the post independent period that, probably, made India the largest private health sector in the world. Its share in hospitals, nursing homes, maternity homes etc., is little over half of all such facilities in the country. The pharmaceutical and medical equipment manufacturing industry is overwhelmingly private and predominantly multinational. Nearly two-thirds of the medical human power is involved in private health care. Despite all these, there is no regulation of practice of this sector of health. The Medical Council, where medical professionals register and which sets standard of medical practice, disciplines professionals, monitor activities and checks malpractices have failed miserably. In addition health sector has provision for regulation in the Local Bodies and the Food and Drug Administration (FDA). The authors suggest certain regulation encompassing the entire health sector, including hospitals and nursing homes, private practitioners, diagnostic facilities and pharmaceutical industries and pharmacies.
A patient's movement to medical ethics is the theme of Duggal and Jesani's paper. Authors explain, historically, the doctor-patient relationship. Before 'scientific' knowledge developed adequately, quackery and experimentation were rampant and which caused great harm to the patients. Elites and rulers availed experienced and reputed doctors whereas the masses were dependent on ill qualified doctors. Efforts to enforce ethics in medical practice are imperative, again, because the registered medical practitioners do not directly elect a majority of the members of the Medical Council. Enforcement of ethics needs to base on principles of non-malfeasance, beneficence, autonomy and justice.
Jesani cites case stories of patients in his comment 'cross practice at the cross roads'. Doctors oppose restriction of cross practice on the basis that 'millions of underserved Indian villagers, who were not looked after by allopaths' will suffer. Jesani cautions the authority to rationalise medical education, care of the sick in villages and standardise qualifications of doctors to control back door entry, cross practice and multiplicity of medical councils.
Khot and Menon introduce accreditation as an approach towards ensuring quality of health care. The authors feel that accreditation should evolve in a democratic manner while reflecting the existing social, political and economic realities.
Some parts of Phadke's work on 'The Private Sector in Health Care in India' is reproduced here. It includes abstract of the report, reforms suggested by him for the private sector and recommended areas for research. The report covered aspects of private medical sector such as general practitioners, consultants, hospitals, laboratories, medical colleges etc., with a view to analyse its appropriateness in fulfilling health care needs of the people.
'Government policies that influence the development of private provision forms part of Berman and Eliya's report titled 'Factors Affecting the Development of Private Health Care Provision in Developing Countries'. The approaches categorised by authors are public production or provision, economic incentives or disincentives in the form of taxes or subsidies, regulation and licensing, intervention in factor or input markets and public information. Each component is explained in detail.
The panorama ends with some relevant data and selected readings on private health sector. The Bombay Nursing Homes Registrations Act, 1949 is also included. This publication is part of CEHAT's information dissemination and advocacy programme on selected public health issues. This is the fourth in this series. The first was on Violence as a Public Health Issue; the second was on Abortions in India and the third was on Health Policy Making in India. Your comments and feedback will be very useful in improving and strengthening this initiative.
Order this publication - A20
Sitemap
© Copyright Centre for Enquiry into Health and Allied Themes