A healthy eye on healthcare

Last week, amid the gloomy drip-drip of bad news about all that is going wrong in the country, there was something to smile about. Prime Minister Manmohan Singh said that there will be a lot more money for healthcare in the 12th Plan.

Given India’s niggardly public spending on health, this ought to be cause for celebration. But I am cautiously optimistic. More money will not necessarily mean better health unless there is political will to enforce greater accountability in the health system. That’s going to be the really tough part.
More money for the welfare of the poor can easily turn into more opportunities for leakage if there isn’t stringent monitoring. Take the case of the National Rural Health Mission (NRHM), a flagship programme. It was launched in 2005, soon after the UPA came to power in New Delhi. Its aim was to overhaul healthcare in poor and populous states by building new clinics and hiring more health workers.
But as we all saw, something was seriously amiss in some places. The NRHM scam in Uttar Pradesh jolted public attention in 2010-11 when three district medical officers in the state were found murdered. There were murmurs that the deaths were a result of the rampant corruption in the implementation of the scheme in the state. Subsequently, a review of the NRHM in Uttar Pradesh, conducted in May 2011 by a 19-member special team deputed by the Central government, drew attention to glaring irregularities between 2009 and 2011. Newspaper reports had also said pretty much the same thing: there were stories about the absence of an open tender system to ensure competitive, cost-effective bidding; absence of clear rationale in selection of implementing agency; and so on. The point here is that scams at this level do not happen if there are checks and balances built into the system and if there is continuous and stringent monitoring on the ground.
India’s healthcare sector is growing at a robust rate and is expected to reach $100 billion by 2015. But this growth will not necessarily mean a healthier India if there is no accountability in the healthcare system, be it in the public or the private sector. A myriad things need to be done towards this end.
Take just one example — the Clinical Establishments (Registration and Regulation) Act, 2010. It was enacted by the Central government to prescribe minimum standards for facilities and services provided by all hospitals, nursing homes and clinics. It is applicable to clinical establishments both in the public and private sector, is linked to all the recognised systems of medicine and includes single-doctor clinics. But hospitals and clinics in many parts of the country still carry on without registration under the act.
Why is this so? Part of the explanation is, of course, the fact that health is a state subject. Since March 2012, the act has been adopted in four states — Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim, and in all Union Territories. The Centre is prodding other states to adopt the law. Uttar Pradesh, Rajasthan, Jharkhand and Maharashtra are also getting ready to implement it.
But this attempt to bring order into a flourishing but unregulated healthcare sector faces stiff resistance. The proposed law has run into a wall of protest from doctors across the country. Doctors affiliated to the Indian Medical Association (IMA) have been particularly strident in their criticism of the legislation. They see it as a return of the “Licence Raj” and argue that it will ring the death knell of single-doctor clinics, small establishments and destroy the future of young doctors. One of the most contentious clauses of the act is its ruling on mandatory emergency care. In June this year, the IMA called for a nationwide strike to protest against the proposed law. Private hospitals were severely affected as thousands of doctors wore black bands and stayed away from work.
It is nobody’s case that a law intended to reform the healthcare sector cannot be debated by healthcare professionals. But should doctors strike work if there is an attempt to regulate medical services?
In an article titled “IMA Strike: Need For Public Debate” in the latest issue of the Indian Journal of Medical Ethics, B. Ekbal, consultant neurosurgeon and former vice-chancellor, Kerala University, flags important issues. Is opposition to the government legislation justified from a professional and societal point of view? Is it ethically justifiable for doctors to go on strike? Mr Ekbal says the act, which envisages that no hospital or clinic can function unless registered in accordance with the prescribed procedure, was introduced “because of the relentless struggle by the Peoples’ Health Movement in India for several decades, demanding regulation of corporate hospitals in our country”.
The health movement in the country, Mr Ekbal points out, has welcomed the government’s move to finally come up with a law to regulate the private sector, but it also believes that the law has “several lacunae and limitations”.
One key concern is “that the implementing, and especially the monitoring, agencies comprise only of bureaucrats and governmental agencies. Independent observers from civil society organisations and health movements have been kept out of such bodies. Moreover, while even solo practitioners’ clinics come under the purview of the bill, the demand for effective regulation and social control of big corporate hospitals is not given adequate importance,” says Ekbal.
It has been also argued that instead of the Clinical Establishments (Registration and Regulation) Act, a system of accreditation can be implemented. Here again, making compliance mandatory will require political will. Though hospitals are broadly governed by the National Accreditation Board for Hospitals and Healthcare Providers (NABH), and laboratories are certified by the National Accreditation Board for Testing and Calibration Laboratories (NABL), compliance is not mandatory.
Which gets me back to the central issue: despite impressive economic growth in recent years, India lags behind many other developing countries and emerging economies in healthcare. Most Indians pay for their medical treatment out of their pocket and healthcare-related debt pushes tens of thousands into poverty. Though India is now considering moving towards universal healthcare, infusion of cash alone will not deliver results in places where they are most needed. A regulatory framework is vital and monitoring will have to revamped, at the field level, and at all stages.

The writer focuses on development issues in India and emerging economies.