You would have noticed how big private hospitals, now flush with private equity, have become posher. The other day, I was welcomed by a ‘customer experience executive’ and led to a waiting lounge. Of course, the glitz and hospitality are only skin deep. I have been in and out of hospitals since childhood, and one thing that has been remarkably consistent is how dehumanizing and opaque hospitals can be.
As I have got more deeply into health, I’ve realized my poor experience is just one symptom of a much deeper illness that afflicts many hospitals — a loss of integrity.
Medicine, like teaching, began as a profession of service. In the 70s, at our family doctor’s clinic in a Bombay suburb, patients would walk in from all social classes, many of whom he would treat for free. Back in my village on the banks of the Cauvery, the only doctor for miles around did not have standard fees — each person paid what they could, in cash or kind.
The first signs that I saw of a corruption in purpose was in the early 90s, when a classmate paid a fortune to get a medical seat in a private college. He is now a wealthy neurosurgeon in the US, so clearly the investment paid off.
As I have got more deeply into health, I’ve realized my poor experience is just one symptom of a much deeper illness that afflicts many hospitals — a loss of integrity.
The last thirty years have seen a rapid increase in private hospitals and medical colleges. Most of these are commercial in nature, driven by revenues and profits. Fuelled by demand from a rising middle class, these enterprises have significantly increased our country’s medical capacity and brought in new lines of treatment.
I know the promoter of one such large hospital chain. A respected doctor himself, he wanted to bring cutting-edge medical care to the country. He has been able to make life-saving surgeries, once only available to the rich, affordable and accessible to many.
Whatever your initial purposes, when you a run a business, eventually the purpose of business takes over. In a highly competitive market, driven by the need to show growth, I have seen the hospital chain slowly change. The earlier vision of ‘do what is right for the patient’ slowly morphed into business indicators of occupancy, revenue and profit.
This is not a one-off story; most well-known hospital brands in India are today held by private equity. Their primary driver is business growth and profitability, so their investments can be encashed at significantly higher valuations.
The earlier vision of ‘do what is right for the patient’ slowly morphed into business indicators of occupancy, revenue and profit.
Likewise, that most private-medical colleges are money-spinners is hardly a secret. Today, unless one gets a government college seat, it takes a few crore rupees to become a post-graduate doctor — and the student is left with no alternative but to recover this by pursuing high-income opportunities.
These doctors then enter these commercial hospitals where their incomes are determined by the revenue they generate for the hospital — in terms of tests, scans, medicines and surgeries. When I enter such a hospital today, I know I am not just a patient but a source of revenue — so I enter at my own risk.
This ecosystem has morphed medicine from a social service into a business and has also stratified healthcare. Quality of a healthcare is dependent largely on how much a family can afford — the poor depend on pharmacies that diagnose and dispense, on the local jholachaap, on small private clinics where painkiller and steroid injections and IV are the primary lines of treatment irrespective of ailment — while those who can afford it will walk into an expensive private practice or commercial hospital.
When I enter such a hospital today, I know I am not a patient but a source of revenue — so I enter at my own risk.
When a public good like health becomes a business, it also becomes morally corrupt. This change in direction is what I call a loss of integrity.
To be sure, there continue to be some medical colleges and private hospitals that have held out and managed to balance these conflicting purposes and pressures. However, they are no longer representative of the mainstream tide.
Is there a remedy to this illness? Some think regulation will help — after all, NMC was a response to the alleged excesses of the MCI. But there are those who say nothing much has changed: while there is lots more regulation, the problematic practices of private medical colleges continue. Irrespective, it will help if the policies of our country are crystal clear and strike against the ‘business-ification’ of public goods.
There are others who think competition will help. But we have already seen what effects the market has had. Although a different kind of competition — from public and public-spirited institutions — offers some hope.
When we started health services in disadvantaged settlements of Bangalore, we had trouble convincing communities to come to our centres — they assumed that since it was free, it would be of poor quality. But with time, effort and word-of-mouth referrals, we have seen demand build up. Today, the same households will visit a private clinic or hospital only if we are unable to serve them.
Recently, for my mother’s knee replacement, we chose a public-spirited ‘mission’ hospital in the city, where we were genuinely pleased with the quality of surgery and level of care. We also know that the revenue from her surgery will help the hospital cross-subsidise treatment for someone who cannot afford it.
In the rural districts we work in, we see a marked improvement in maternal care in government hospitals. Many communities now choose to go there for their pregnancy instead of private maternity clinics.
These days, many medical aspirants prefer a government medical college not just because the fees are lower, but because the attached teaching hospital offers a real diversity in case load, and hence a more comprehensive medical education. Medicine is at heart a service-oriented profession. When it is affordable, of good quality and done with the right value orientation, students in turn imbue this ethos, and choose medicine not for the money but for the service.
In the rural districts we work in, we see a marked improvement in maternal care in government hospitals.
So, while regulation has its place, perhaps the real challenge to the growing commercialisation of healthcare will come when alternatives are visible to the common man — and this is emerging both from the public health system and from public-spirited health organisations. While we have drifted from the core ideals of public health, I hope and believe we will see a return to the roots.