When Public Physicians Go Private: The structural crisis in healthcare
Conversation between Professor T Sundararaman (TS), Dr Yogesh Jain (YJ) and Dr Vikash R Keshri (VK) on the problematic of private practice by government doctors.
(please also read the attached preliminary report on the situation in different states)
The public good- Government doctor at a public facility.
VK: The first question, and this is a question for both of you: to what extent should we consider private practice by government doctors as a problem?
YJ: Let me place such a question in context. What other cadres of workers–who in public service, whether it is teachers, engineers, bureaucrats, police or judiciary–who have service rules when they are employed by the state, would they be doing private service in violation of these rules? Very few. Some of these are cadres who do not have any margin for any work outside their public responsibilities, like judiciary and the police. But others, including managers and engineers, could do so but do not. The work of physicians, and college and school teachers is comparable public services. The exception would be lawyers where the profession is completely private, except for the small quarter of government lawyers and public prosecutors.
It must be called a problem as in most circumstances private practice compromises their contribution and their commitment to the public service. We would say that for teachers too; if when employed by the public system they are not spending time with the given responsibility, and instead doing something personal in financial interest, which adversely affects their primary contribution. And I would contend that physician employment, is 24*7 contribution for anyone employed by the government, and the notion of working private practice beyond duty hours is ill conceived. As per most service rules the government employment is on a 24*7 basis. One may be called upon to work at any point in time. Working outside impacts on their contribution, considering that it is both physical presence and your mind on the job.
Further, it is a problem in an unequal society where the dependence on a functioning public system is the only available healthcare resource that is available for a large majority of people. There is a structural problem if public physicians are practising outside their primary responsibility.
TS: Yogesh has made some powerful points. Let me add to them. The reasons why private practice should not be allowed are the same reasons why public services are required in the first place. There is a very high degree of information asymmetry and uncertainty in the nature of medical care leading to complete market failures. This means that provider’s gains are not aligned with patient interests and the consumption of healthcare is supplier driven rather than need-based. Purchasing healthcare on a fee-for-service basis at the point of care, based on out-of-pocket expenditure, is the most regressive form of financing healthcare. The whole effort to build a public service was built around this particular understanding. Allowing private practice undermines it.
There is a private market in healthcare which is allowed to proceed in parallel, but if a provider is in private practice, he gets an incentive over and above what he is already assured in the public sector, and this will drive the latter. This is also a conflict of interest for providers, because the clientele is the same. And given the power dynamics the choice of where the patient is provided care is not in the patients’ powers even where it appears to be so.
YJ: If I may add a bounce-back question to you Sundar from here? Are there other public services where dual practice could be considered as not a problem?
TS: It is difficult to say. If the clientele is completely different, then perhaps there would be no conflict. In law, where the defendant cannot pay, the court appoints somebody to give legal aid and this is publicly paid. An engineer with the government cannot be part of the contract. So, in such contexts there is no conflict of interest. But in private practice by the government doctor, there is always a conflict of interest. It can be better managed or poorly managed, but it is there. I don’t readily have any other profession or occupation where such a duality can exist. Imagine a police detective taking up some murder cases as a private investigator and charging fees from relatives for the same case. There’s a degree of absurdity in doing so, and for professionals to claim that this medical profession is exceptional does not stand to scrutiny.
VK: Many doctors feel that such private practice is legitimate. They would argue that employment is a commitment to only 8 hours and if they are willing to work beyond that, it should be allowed. Or more broadly, what are the justifications for private practice to continue?
TS: Yes, one of the main reasons advanced for legitimacy, is that we are giving eight hours with the government and beyond that, I can work and be available to those who seek my care. Of course, this boundary is seldom followed and most doctors in private practice are not available on afternoons or on call. But even if followed it would not be correct. The logic of the 8-hour working day is that it is the maximum desirable working time for a person to work productively. The other 16 hours is to rest and pursue other necessary interests for self-development, to be able to remain optimally productive. There is time needed for reading, reflection etc. In medical colleges additional time is needed for students, and for research activity.
Another justification is that if it is not allowed, doctors would exit public service and there would not be enough human resources left. We hear this argument most in states where private practice is illegal and this is reasonably enforced, like Kerala, Punjab, Himachal etc. This was a bigger problem earlier, but the fact is that today there are enough basic medical doctors available, and even basic specialists for most states. Those with an interest in public service may be less, but this would still be enough for recruitments. For most positions the number of applicants would be much more than the number of vacancies. Except for a few specialist positions, you would not be at a loss for public providers if private practice is altogether disallowed.
Another justification that is popular in the medical profession is that medical service is inherently private in nature, and public services is in the nature of some charity. It is “residual care” meant for those who cannot afford private care. Like being provided state funded legal aid if you cannot pay for your defence lawyer. So, you do not expect affluent patients or even middle-class patients to come to the crowded public hospital. In this understanding the patients’ right to access healthcare of his choice is restricted by not allowing the public doctor to offer private practice.
The fourth argument, often from the elite, is that by allowing private practice, the elite can access his service in the evening at a premium, while not taking up his morning time in the public space, where the poor get prioritized. There is some justification for this. But only if people were to adhere to the rule. But many providers who by choice do not undertake private practice even when allowed to, know how to do this, by giving appointments to see them in the afternoon or a less demanding time. But remember this cannot be a general principle, for even the poor require a fair allocation of the doctor’s time.
These last two problems can be mitigated if patients in a public hospital are allowed to follow up with a provider of their choice and there is a space for seeing patients by appointment. There is no rule against it, and since provider-patient trust is important, this should not be objected to. But it does not happen. In public service, generally, the system doesn’t allow you to choose a doctor with whom you want to follow up. This is one reason why many patients ”choose” to go to the private practice, often enquiring of the doctor, whether they could be allowed to do so.
YJ: And all these four arguments can be countered, but I would add that this eight-hour schedule implies that one is available for the patient throughout the day- the duty day or so-called active clinical duty. Your mind is also part of the commitment, not only your time in working hours. This would not hold true for any other profession outside medicine. In clinical care your entire time is a commitment to your principal employer- the patient. If you are seeing private patients over and above those you saw during the day in the public hospital, you’re thinking about them also, but you are needed to focus on your primary employer- your patients as a public provider. It’s not just to be counted in terms of when you are hanging your coat in that hospital or health centre.
VK: Health in India is a state subject, and different states have different laws and regulations for regulating private practice by government doctors. And there are other government employers. What is the extent and pattern of this problem across states and public employers?
TS: In preparation for this conversation, we shared an interview schedule on this issue with a number of our friends who have been following and contributing to the conversations from different states. We have put together their information as a Preliminary Report on Private Practice by Government Doctors across states.
There are broadly four types of patterns seen.
The first, the best-case scenario, is where no private practice is allowed, Non-Practicing Allowance (NPA) is paid, and the rules are followed. In this scenario there is no illegal private practice or only occasional instances which are deviances. In this pattern we have all the central government–institutes including the AIIMSs, PGIs of Chandigarh, Lucknow, Patna etc, JIPMER, NIMHANS, Tata Memorial (Cancer) Hospital Mumbai and others. In this category we should also include the hundreds of ESI hospitals, the large hospital networks of the defence establishment and the railways. Then we must also include the very many hospitals which are part of public sector undertakings like in the mines, thermal power, coal, steel, nuclear power plants and many other undertakings. Together this is very large number of public hospitals where there is no problem of private practice, and therefore no conflict of interests. Hence, a generalization that banning private practice in public service is not possible, is seriously flawed and ill informed. Most of these public hospitals are premier hospitals of the country on par with the best in private sector. In the case of public sector undertaking, they are provider of first resort and most trusted for its employees. Among states, Himachal, Delhi and to a large extent Haryana are good examples where private practice is not allowed, and barring the occasional deviant, the rules are followed. So, even the statement that state health services cannot achieve this is ill informed. Almost all the health services cited above allow for an NPA which is at 20 % of the basic salary and is part of the salary for purposes of computing and paying DA.
Then, at the other end, the worst-case scenarios are the states where private practice is legal and there is minimal effort to manage conflict of interests. It is literally a Laissez Faire policy- or lets-look-the-other-way-policy that is in place. Here we have Jharkhand, Bihar, Odisha, Uttar Pradesh, Rajasthan, West Bengal and others. The adverse impact on public services is terrible. At the medical college and district hospital level, quality of care suffers, the time spent at the hospital is low and teaching is seriously affected. The role model for students is also terrible. At the PHC and CHC level, in addition to the above, there is absenteeism that takes two forms. One is when the doctors take turns to come to the facility with one doctor coming and the others away in private practice. The other is when the doctor comes to the public outpatient clinic for some time and for the rest of the time is at home nearby where he is seeing private patients. Paradoxically, this latter practice is zealously defended as representing patient choice, and there is a sort of evidence that the doctor may provide better care there. Typically, in such contexts, bed occupancy in the CHC level would be very low or absent. Such states are not the rule, but the exception, but these exceptions are large enough and occurring in the states with the highest health inequity and lowest health outcomes- and therefore we need to be worried. Courts in these states have often taken cognisance, but given limited governance capacity, there is little headway.
In between these two polar scenarios, there is a context like Punjab and Maharashtra, where private practice is illegal but poorly enforced. In Punjab for example, enforcement is limited to ensuring that there is no private practice in duty hours, and there are no referrals to their own nursing homes. Some specialists thrive in private practice, but for the most part, private practice could be a modest supplement, and the main attention is to the public service. But even in this relatively better scenario, teaching and research is affected in medical colleges, and the stake on developing the public services, especially for more advanced and complex care, is weakened.
The major scenario would be states where private practice is legal, but conflict of interests is actively managed. In many of these states, for some of the cadre, private practice is not allowed and NPA is paid. The success in conflict-of-interest management in these states varies widely. However, for precisely this reason, we should study these states, for there is much learning to be had that could help an incremental approach. All the southern states are in this group.
For example, in Kerala, private practice is not allowed to medical colleges and administrative staff, and there are a number of onerous restrictions on practice in district hospitals and sub-district hospitals. Like private practice should not be within one kilometre, it cannot be in commercial establishments, nor involve using advanced technologies, nor allow cross-referrals, etc. These restrictions are not uniformly observed, and even in medical colleges, there are breaches. There is also resistance from medical officers. However, as compared to other states, private practice is much reduced.
In Tamil Nadu, all those in the public health cadre under the directorate of public health and the administrators in other directorates are not allowed private practice, and to a large extent this is followed. Unlike in all other states the NPA paid is a trivial amount. For all others the practice is legal, but there is little absenteeism, or compromise in public services, or inappropriate referrals. Doctors in any level can opt for NPA and exit private practice, but the NPA is set at the level of Rs 2000 to 3000 per month. So, this is not taken very seriously.
In most states where it is legal and conflict-of-interest management is being attempted, this consists of mainly preventing private practice in duty hours and restricting private practice to the home and disallowing it from commercial hospitals. But even this may take considerable effort. In Assam, a recent order makes private hospitals responsible to ensure that no public doctors are working in their facilities and duty hours, with de-registration under the clinical establishments act is they do so. In Chhattisgarh, private hospitals allowing public providers at any time to provide services can be de-empanelled from their universal public health insurance programme. In Karnataka, a referral from public to private hospital by same provider for a procedure under the public insurance scheme can be identified by digital tracking and the likely action is a transfer of the provider. And so on.
But if you go through the feedback from the states we recorded, conflict-of-interest management has modest impact where private practice is legal, and illegal is only as good as its enforcement. But that being said, both of these scenarios are much preferable to the worst-case scenarios. So even a weak effort at conflict of management is better than no effort at all.
YJ: If you look at the pattern, the level of private practice matches with the quality of public systems and trust in it. The central Indian states, which are the last rungs of the ladder in access and quality of healthcare, and in the effectiveness of public health systems have the higher prevalence of unsupervised private practice. I think the other key point brought out in the accompanying report, is that regulation helps but rules are only as good as they are enforced. We have situations where even people who are pursuing this post-graduate training in surgical specialities have to actually learn in the private clinics of their faculty members, like I know in Agra and many other middle-sized cities. In Bengal also, the faculty members would take their junior residents to learn procedures in private clinics, and even do their thesis and dissertation topics in private clinics. So that is probably the lowest you can drop down to in terms of ethics. So private practice adversely impacts the quality of care and quantity of care to the marginalised, for whom the only source of care is public hospitals, but in addition all medical education, both at the graduate and post-graduate levels, is seriously compromised. Research, an essential function of medical colleges will remain a non-starter.
I think the other additional dimension I would add to this is the diagnostic services provided by the para-clinical subjects like microbiology, pathology, haematology, and biochemistry. These would be departments where adverse impacts in these states, would be probably much worse than even clinical departments, and the level of privatisation and denial of care in public facilities could be close to 100%.
VK: I note the four patterns. But are the determinants only regulatory? What are some of the non-regulatory or non-legal factors which contribute to doctors adhering to not doing private practice. You point out a large category of doctors who are working in the public sector, but not at all practising privately. So, what are non-regulatory factors?
TS: I think both work-culture and role-models are important. In the central government institutions, like the railways or many central government institutes, there is an established work culture and provider behaviour norms, and those in violation of it for monetary gain will be frowned upon and seen as cheats. Whereas in the worst-case scenario states, eminent and famous public physicians and surgeons are famous as private practitioners also. Lack of success in private practice could be seen as a comment on their capability. But this would not be true in Himachal or Kerala.
The second major non-regulatory determinant is what is called a “positive practice environment” where actually there is a huge degree of professional satisfaction from the fact that you can provide the best quality of care to even people who are not able to pay. Here professionalism and professional ethic is of the highest order. This is true even in the private sector. Most private medical colleges cannot think of banning private practice outside their hospital. But in a hospital like CMC Vellore for example, where the pay is substantially less than private sector and even less or comparable with what governments pay, you do not have private practice outside the hospital. The only reason is a strong professional ethic, which is related to doing your job well. But for this, to be perceived the specialist, he must be allowed professional autonomy in his clinical work, encouraged to attend conferences and share his knowledge and achievements etc. But in public hospitals this is not always the case. Specialists could be posted in a district hospital, or CHC where the equipment and patients and autonomy to practice his specialisation is limited. Then, a practice outside the public hospital helps retain his skills and professional status. A public sector gynaecologist who has no space to do anything but sterilization surgery and deliveries and cannot perform the whole range of professional skills that she is trained for, is likely to exit unless she has private practice in parallel. If you look at the best-case scenario hospitals I mentioned earlier, all of them provide the full scope of professional practice (relatively). That, I think. a positive thing.
Professional autonomy and satisfaction are also important. The “principal” for every specialist is the patient and not the administration. You cannot be calling the specialist away for all sorts of administrative functions, or be supervised by bureaucrats, or be harassed for targets, which are often set without any sense of public health or clinical medicine. Of course, technical administration is required and for this an administrative cadre is important. Most persons in purely administrative practice have to opt out or decrease clinical work. In primary healthcare the logic is different, but even here, it is important that the doctor is able to have the satisfaction of providing patient-centred healthcare, rather than as implementing a number of vertical targets where the patient is only incidental to registers and forms. Patients being allowed to seek appointments with doctors they have been seeing earlier for ensuring continuity of care, is also essential to build in professional and patient satisfaction.
Specialist and doctor exits from government services will be much reduced, and one would evolve a team which is actually interested in public services, only if these conditions are provided.
I also note that the policy on private practice has much to do with transparency and lack of corruption in transfers, postings and appointments, and indeed with all aspects of workforce management. Doctors with a flourishing private practice are more threatened by transfers and more vulnerable to pressures of payment to keep their position or move to a position of choice. Once a cycle of corruption is set up, accountability is compromised at all levels. This works both ways–enforcement of rules regarding practice would be better where transparency in postings is better and vice versa.
YJ: So, if I may add to this. I have full agreement about work ethic, work culture and professional satisfaction that drives in a non-regulatory way the avoidance of private practice by public physicians. Healthcare is, let’s face it, a socialist project. It is not market-determined. Even in a capitalist economy like UK and most of western Europe, healthcare for all, at least, is a socialist project. So, therefore, beyond a work culture, societal culture would also be an important determinant. What does the public perceive? A public perception which calls good public services, would prevent public physicians from doing private practice and feel rewarded in the respect that they would get in a good, well-functioning public system. That would also explain why in UK, though the NHS allows every public physician officially half to one day that they can take off for private practice, this does not contaminate the NHS service provision. So, while many NHS doctors, especially at the hospital level, do some private practice, it is in a very limited way. It’s not just peer pressure but a norm established by a good social culture. In Himachal also, it is the societal norm that can explain why private practice has never been a problem in that state.
TS: There is some bad news here. Himachal government has recently announced stopping their non-practising allowance (NPA) for new entrants, giving rise to staff unrest and strikes. Further they have started outsourcing the employment of doctors to HR agencies, who, instead of the government, would contract the doctors, and they slashed the entry level salaries. When concerned officials have cautioned the government, the careless and callous reply is “No, no, we will manage it, because there is a surplus of doctors available for recruitment. We will manage it by administratively enforcing our rules.” Now, this is really a step backwards. For, you are forcibly converting an exemplar, an outlier best practice into a defeat. But this helps illustrate the complicity of governments and government policy in leading to the mess we are in. And that this is happening when the state government is under a political party committed to welfarism makes it even more tragic.
VK: So just one another on this. Do you think that different forms of incentives also play a role in doctors indulging in private practice?
YJ: I don’t think monetary incentives work. It is largely the other incentives that Sundar talked about, like protection from bad service conditions, rules and political interference, arrangements for career progression, and professional satisfaction that work. Monetary incentives are never the most important thing.
TS: The model for the central government hospital and indeed for public sector undertakings was that if you pay professionals an adequate remuneration, which broadly is the pay commission salary with the 20 percent NPA and also provide basic facilities, then they do not have to worry about these, and can dedicate themselves to public service–that was the principle. For example, if you come to AIIMS or JIPMER, you have housing, a good school with modest fees for your children, a small shopping centre within, now they even have a swimming pool which wasn’t there in my days. These are above the general average and in the top 1 percent of the population. But if they start comparing these with the top specialists like a public cardiac surgeon saying “If I was in the private sector, I would be earning this much per day”, then there is no meeting these expectations. Now you are saying “no, no, unless you give them higher monetary incentives of private practice,” they won’t work. Neither then, nor now has it worked. Take care of the essential needs, create a positive environment and actively promote a public-professional ethic.
VK: Great. Can we go back to the consequences? How will we classify those consequences, and what are, kind of, the larger complications due to that?
TS: The first or the most worrying is the denial of care. This is the most serious problem and feature of worst-case scenarios. It’s not a major feature of the other two “dual practice” scenarios. In all “dual practice” scenarios, there is a compromise on quality of care because of the limitations of time and the distribution of mental attention between the public and private patient. While essential services may not be affected where there is partial regulation, when it comes to upgrading to provide more challenging services, the additional effort and risk is avoided and thereby there is considerable denial of tertiary care that could have been provided. There is also a weakening of public services from within. This is something of a rare situation. Usually, when there is a privatisation of a public service, the workforce of the public facility is one of the strongest defences. But the medical workforce is also weakened from within, disorganized and does not even fight for huge delays in promotions or for unfair transfers and such. It also undermines the health of the private sector. For one, there is an unfair competitive advantage for the private practitioner who is a government employee. And then, since the district medical officer, who himself may be in private practice, is also the main regulator under the clinical establishments act, regulation of private sector too gets undermined. And again, since the district and state medical officers are also administrators to various degrees of the publicly funded health insurance programmes, complaints of over-billing, or double billing, or denial of entitlements under the scheme are not adequately acted upon. It also seriously undermines medical teaching and research. And when research is undermined, medical excellence is undermined. One of the big programmes now is building 16 new AIIMS, but if the leading state medical colleges have the same credibility, this may not be needed. Even now, the new AIIMS are all recruiting from the same pool, with the exception that there is a decent remuneration and terms of employment and no private practice. So, the damages of this practice are extensive, across the whole board.
YJ: I would emphasize that the large impact is on medical education, which gets completely trivialised and, shall I say, marginalised. Students do not learn because the teachers don’t have the time to give, and in whatever commitment of time they do give, it is education that gets most compromised, both at the graduate and at the post-graduate levels. And research obviously will remain a non-starter. But I think the largest damage that happens is the systemic damage to public systems. Their growth is compromised. The image and the possibilities of a public system being the dominant form of healthcare, the dominant port of call for people gets compromised. And finally, the image of physicians is also compromised. They are perceived as working in their private interest, and not for patients or much less the public at large. Healthcare is called a noble profession because, at some level, you are often working against your personal interest. That was the basis of the word noble. Physicians feel hurt by the decrease of public respect that they were used to, but do not perceive that the public, even while it seeks their care, may not do so with the same levels of trust as they did earlier. And I think that is the lasting damage that you do, besides the immediate denial of care.
VK: So, what is the solution? Can we completely ban private practice? Is it possible to completely ban private practice? And if not, what are the other options to manage private practice by government doctors?
YJ: If we agree on the damage caused, and we know about the best-case scenarios that are widespread, we should argue a complete ban on private practice by all government doctors. It does seem impossible to implement in many states, but this must be the direction we set. Let us look at the legitimising arguments Sundar outlined earlier.
About holding to ransom that specialists would leave government service in large numbers, and this would threaten the existence of medical colleges, etc. My view is to give them a polite handshake and move on. I think we should be able to handle the medical colleges and public hospitals without such socially compromised professionals, if I may call them as that. But yes, as strategy, I would suggest, a phased approach, and not a full ban immediately. What can be done, and a few states have already done, is ban private practice by public physicians in the medical schools, and then in all hospitals of the big cities–tier 1 and tier 2. Again, learning from the many states who have done it, ban private practice for public health administrators and hospital administrators, especially the chief district officer and second level district officers too. The second would be if we are able to have a regulation of ethics and quality of practice, not only in the public system, but in the private sector as well. This may take time, but we can start with measures like strictures against kickbacks and commissions, transparency or rates, insistence on abiding by contractual terms of publicly funded insurance programmes, etc. It is difficult to think of a successful public service functioning as an island within a very unregulated and often unethical private market for healthcare. But for starters, I would like to bite the bullet and say, yes, we must ban the private practice and the only requirement to do so is the political. Courts are likely to be supportive, but careful legal articulation would, of course, be required.
TS: I agree. But I would insist that any measures at banning or regulating private practice by government doctors must come along with packages with some positive measures and incentives. One basic is a 20% NPA, considered as part of the salary. This works, it has widespread acceptance, and should become the all-India norm. The less developed states could be financially supported if implementation is good. Second, the opportunities for the exercise of professional skills and the ability to upgrade them as required. This should be like an entitlement, with paid leave for coursework, but of course a bond to serve for 5 years or more if it is a longer course. The details could be worked out. The third is to ensure that those who prefer to remain in clinical and not enter administration are allowed to do so. That may require, like in Tamil Nadu and a few other states, a creation of a public health cadre dedicated to non-clinical administrative and public health functions. Further, specialists require to be posted in departments or hospitals where they can be specialist practitioners. Recruitment policies should reflect this. Making recruitment policies more efficient, and there are many good states that are examples of this, would also help.
On banning private practice, firstly ensure that current bans, which come packaged with positive measures, are not undermined, like what may happen in Himachal. In other states, it is as Yogesh suggests first administrative cadre and all medical colleges, then all hospitals in tier 1 and 2 cities and then the rest. There are many social reasons not related to private practice for preferring postings in tier 1 and 2 cities, and given the other elements of the package, exit of current providers with a large private practice can be replaced with others who seek such a posting. Given how power plays out, if we get past the first two step, the third phase will have little resistance. It is the specialist of the tier 1 city who would be difficult to convince.
Another important measure is that the Clinical Establishments Act or equivalent state legislation should be aligned to this goal. There are many ways to do this. Thirdly, publicly funded health insurance programs should also disallow empanelment of nursing homes whose services are by public doctors in contravention of the service rules which are in place in the state.
The Indian Medical Association and private nursing homes associations are silent on this issue or are conflicted internally. In many ways those in dual practice are an unfair advantage to those who are only in private practice. There is a need for an outreach and negotiation that also helps private sector in providing quality care, so that they supplement, and do not find themselves in competition with the public sector.
Broadly, I think these are achievable goals. Because of the much larger availability of doctors and specialists and the considerable under-employment in the private sector such a transition should be possible now, even where it was not possible earlier. But we will need to actually create this public understanding of these issues, and a political understanding.
Till such time as the political will is created, active management of conflict of interests is essential and feasible, and this will limit the damage done to public services. But as we have observed, its impact is modest and limited to physical presence in duty hours, and that is just not good enough.
VK: Dr Yogesh, would you like to add something?
YJ: My own understanding is that the past efforts in curbing private practice have failed because there has been a cosy relationship between people who are powerful, whether in healthcare, or the elite in bureaucracy or even the political establishment. And I think it is doable provided there is political will and if it is done with all the cautions and the supportive steps that were just mentioned.
TS: Yes, political power and ideology has a lot to do with it. Clearly this problem can be overcome, and in many areas, it has been overcome. But if there is no will to increase public funding and public provisioning, and thereby lead to passive privatization, it becomes convenient to express helplessness in dealing with this problem and blame the entire problem of poor quality public services on the errant doctors.
There is also a differentiation within the medical profession. Not all doctors in private practice are making huge profits and even many small hospitals are struggling. There are many who see more medical representatives per day than they see patients, whose earnings are more from commissions than they are from fees. Also, the business model has shifted in the private sector and the return on investment is from higher cost drugs, diagnostics and procedures than from consultation fees. It is only a small and decreasing proportion of specialists who are actually making most of the returns. I think we need to be able to deal with even the professional in the private sector in a more differential and interactive way and be able to identify their problems and encourage the many ethical providers, who are unable or choose not to be in government employment, but whose motivation is still of public service. But that is another conversation.
VK: My supplementary question to Dr Yogesh is the challenges of non-physician engaging in private practice.
YJ: I would say here the issue is no different from that of public physicians doing private practice. Whether it is laboratory technicians, pharmacists, radiology or radiotherapist technicians, nurses, operation theatre attendants- working in private practice within duty hours or after, the problems are similar. It compromises work in their own departments and public workspaces. It leads to denial of care, and a siphoning of human resources, as well as material resources towards the private sector, those who ought to be the custodians of the materials in the public systems.
I think these cadre would be easier to manage, once you are able to control the public physicians from doing private practice, because in most places in public systems, physicians are the leaders of the team and if the leader is compromised, you cannot control the rest.
We may require home care on some occasions but these have to be planned for, and that is yet another discussion.
VK. What about the role and regulation and banning of non-formal, non-qualified practitioners providing health care. When we are talking of controlling private practice by government doctors, why are we not talking of that?
TS: Interesting that you raise it like that. Many of those interviewed even for this conversation, did have this response. It is a serious issue, but a big topic in itself. We cannot pack it into this. We will take up that issue in the near future.
Acknowledgements:
The information about the current situation in the states was collected by an interview schedule administered by one of the RTH collective friends in each of the states. The Preliminary Report of the study is attached. We thank every one of them for the voluntary time and effort they have given to this work. Since many wanted to maintain confidentiality in talking to us, we have not named them in the acknowledgements. Some interviews were directly conducted by the editorial group of this conversation. Thanks to Vikas Keshri for his contribution to developing this conversation and its background report and to Roubitha David for the recording and transcription.
About the participants:
Dr. Vikash R. Keshri, MD, PhD
Executive Director, State Health Resource Centre, Chhattisgarh, India
Adjunct Senior Lecturer, School of Population Health, University of New South Wales, Sydney, Australia .
Dr. Vikash R. Keshri is a Public Health and Health Policy and Systems Researcher (HPSR) with a keen interest in policy analysis, governance, human resources for health, health systems performance and burn injury. He is a medical doctor with an MD in Community Medicine and a PhD in Global Public Health from the University of New South Wales, Sydney, Australia. He was an inaugural Keystone HPSR fellow and did health policy analysis studies at ITM, Antwerp, Belgium. Dr Keshri has long experience in public health, both in India and various other global settings. He has worked closely with policymakers and health systems stakeholders in most resource-constrained states in India and contributed significantly to policy change and health systems strengthening. Dr. Keshri’s research has been published extensively in prestigious peer-reviewed journals, such as the Lancet, Lancet Public Health, BMJ Global Health, Human Resources for Health, Burns and others.
Presently, Dr. Keshri is the Executive Director of the State Health Resource Centre, health systems think tank offering technical expertise and research support to the Department of Health in Chhattisgarh, India. He is also an Adjunct Senior Lecturer, the School of Population Health, University of New South Wales, Sydney, Australia.
