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Rapid Responses: Rapid Responses published:
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The private health sector in India:An incisive anlysis
- Dr. Parthasarathy K S (18 November 2005)
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Lack of Governmental interest in Health care in a Democracy ! Possible only in India.
- Sita Rama Rao PODILA (19 November 2005)
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Encashing on medical tourism & regulating private practice in India.
- Mangesh A Thorat, Priya M. Thorat (19 November 2005)
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Medical Scare Industry!
- BM Hegde (19 November 2005)
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Using medical tourism to contribute towards the government sector.
- Dr Milind Karale (19 November 2005)
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Health Tourism to India should help the poor
- Peter D De Mello (19 November 2005)
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The private health sector in India: Helping India earn foreign exchange
- Dr. Bichitrovanu Sarkar (19 November 2005)
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Medical Tourism: India and the UK
- Sanjay Bhattacharya, Basumita Chakraborti (20 November 2005)
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Private enterprise:Evil or a boon in disguise.
- Tarun Durga (20 November 2005)
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Single Level Health Care Is the Only Solution
- Shyamal Bagchee (20 November 2005)
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Let's not confuse the issues!
- Rajan TD (20 November 2005)
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Private Health care, a Silver Lining to Indian health system.
- Omendra Narayan (21 November 2005)
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The private health sector in India
- BIJU BASIL, MAJU MATHEWS (21 November 2005)
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Profit and profiteering
- Abhijit M Bal (21 November 2005)
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The reason for rapid growth of private care in india
- Dr Jayaraman Nambiar (22 November 2005)
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Private Healthcare at the cost of Public Healthcare?
- Amitava Bose (22 November 2005)
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Private health boom in India
- DINESHKUMAR THANIGACHALAM (23 November 2005)
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Other drawbacks of medical tourism
- E Suresh (23 November 2005)
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Conflict of medicine and commerce
- VANI BADRISH KULHALLI (25 November 2005)
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Where private and public meet
- Amitava Banerjee, Oxford, UK (30 November 2005)
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Health care system in India - headed for nowhere
- Dinesh Singhal (7 December 2005)
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Is Legislating Private Health Care a solution?
- Dr.Sumanth C Raman (7 December 2005)
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The public health sector needs more accountability
- KC Mahajan (10 December 2005)
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Dr. Parthasarathy K S, Retd Secretary, Atomic Energy Regulatory Board Mumbai 400094
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Amir Sengupta and Samiran Nundy made an incisive and informative analysis of the health service offered by private hospitals in India. They vividly described the cash starved condition of the public hospitals and certain not admirable features of the private hospitals.Recently there has been a spate of Public Interest Litigations against private hospitals. It was alleged that these hospitals do not comply with the conditions under which they secured land from Government in prime locations.They were expected to offer free treatment to a few poor patients and subsidized treatment to some patients in the low income group.Court-appointed committess have seen an element of truth in the allegations. A factor not referred to in the article by Sengupta and Nundy is that some private hospitals follow the unhealthy practice of appointing "marketting executives" and "public relation officers" to persuade physicians to refer their patients to go for expensive diagnositic tests such as MRI and CT scanning.It is difficult to prove such arrangements. Recently I came across an advertisement in a daily newspaper asking persons with certain risk factors to go for cardiac Computed Tomography (CT) scans. Interestingly "universal" risk facors such as "stress", "Erratic life style(long working hours,presssure! etc)" were included. Since any one living in a city such as Mumbai is likely to be victims of any one or more of the risk factors, the advertisement is clearly aimed at mass screening of symptomless persons. Professional associations in USA did oppose such practices in their country.Some private clinics depended on the endorsement of celebrities for their survival! But they did not get the requisite number of patients.Many such clinics who did scanning of symptomless patients closed shop. The day is not far of when we see a tennis/cricket player or film star in India endorsing CT scans! Sengupta and Nundy stated that the private hospitals are getting exemptions from taxes and duties for importing drugs and high tech medical equipment;I think that this is not true. They have to pay taxes and duties as if their enterprises are commercial. Competing interests: None declared |
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Sita Rama Rao PODILA, Staff Grade in Cardiothoracic Surgery University Hospital of Wales,Cardiff U.K.
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Dear Editor, Dr S Nundy and Mr SenGupta need to be congratulated for focusing on this issue which many Indians are silently suffering. Many thanks for writing the article highlighting the lack political will and public interest in state funded health care. You were also correct in pointing out how the standards of district Government Hospitals and Medical Colleges were much higher in 1950 -1970s, certainly in Andhra Pradesh. Recently, I worked and seen myself these issues in Visakhapatnam, second largest city in Andhra Pradesh. It has more than a million population and a 10 million referral base with no proper level 3 intensive care even for the rich! I have seen the spurt in trauma in the new dual carriage ways that are not complemented with any semblance of trauma care. Every district in country needs one or more AIIMS standard hospital. Only then we can think of using the word ‘developing’ before India. If this is achieved public will have local access to high standard care and training. The sad state of current rural neglect decreases and perhaps we will not see as many doctors leaving the country or failing to return. Currently, people all around are trying to make sense of diseases and disasters from limited information coming through some television based health programmes while surviving through Dengue fever, drug resistant Malaria, Tuberculosis and AIDS besides a host of other 'modern' diseases. There is no leadership, no Government has ever been accountable for health care or major railway accidents or any other disaster. I will try to shine light on the other side of the coin, i.e., Medical Education. We have now much diluted standards in Medical Education. I have seen myself how there are no patients in Government District Teaching Hospitals in Andhra with ward after ward having empty beds. The diseased population has lost trust in these Hospitals and there is no teaching. This is some thing unimaginable 20 years ago. Many medical posts are unfilled as a part of cost cutting measures whilst many doctors are unemployed outside. In this background we have proliferation of private medical colleges. Ex-members from Indian Medical Council (IMC) offer lucrative consultancy service to the rapidly growing Private Medical Colleges. They advise on loopholes in Indian Medical Council regulations and how to gain accreditation from IMC with least numbers of Medical staff. Sadly, even the Government Medical Colleges adopt these fraudulent shortcuts like moving around Government doctors from local Primary Health Centres to temporarily fill in vacancies in Medical College Hospitals prior to an IMC inspection. Some of these are two day transfers!! If IMC’s own standards are even half rigorously adopted many of our longstanding postgraduate teaching programmes may have to close. A classic example is having super- specialty training (MCh) in cardiothoracic surgery in Osmania and Gandhi Hospitals in Hyderabad. No students are enrolling in to these because they know there are no facilities to perform these operations in adequate numbers. But the centres are still recognised by IMC. The main question is –is there any leadership interest in the Government regarding Standards of Medical Education and providing health care for its one billion population? Perhaps we should look into these basic issues more carefully than prioritising our efforts to get a United Nations Security Council seat. Yours sincerely P Sita Rama Rao Competing interests: None declared |
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Mangesh A Thorat, Specialist Registrar Dept. of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400012, INDIA, Priya M. Thorat
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We congratulate Sengupta & Nundy 1 for their excellent perspective on private healthcare in India & a very conscience-based approach in dealing with the issue. However, we would beg to differ slightly from them on the issue of institutes formed through corporate or foreign funds. Such corporate private hospitals (CPH) do not directly endanger health of an ordinary Indian patient. On the other hand, these are bringing in significant amount of investments & profits as service providers, which results in increased employment opportunities here. Secondly, by providing global-standard care in India itself, they are creating a benchmark against which the rest of the healthcare in the country can be compared; not to forget that some public-funded institutes offer better treatment sans five-star amenities. Medical tourism boom can be encashed by levying a nominal tax in foreign currency for every foreign patient treated, where the tax money will go in a public fund created to buy medicines for poor patients. Efforts should be made to make use of such opportunities for the good of our poor patients rather than antagonising them. Second important issue the authors overlook is the one of unregulated nursing-home-based private practice. These are generally small, few-beded private enterprises with the clinician doubling-up as a manager & multi-disciplinary care is usually not available. Majority of the private practice in this country is concentrated in this type of enterprises; almost all newly qualified clinicians want to start their own enterprise to reap the obvious profits. There is no standardisation or regulation of care in such nursing homes. They often cut corners in spending on equipment & facilities required for safe treatment practices. The ultimate loser is the poor patient, who ends up coughing up a lot of money to get substandard care in most instances. It has been shown time & again 2 that multidisciplinary institute based approach has much less chance of clinical or judgemental errors & better patient outcomes. It is the time we focus on this area to regulate such practices & encourage institutionalisation of private practice in this country. It will not only benefit the patients but will also help clinicians improve their knowledge & clinical skills through peer pressure apart from facilitating research. References: 1.Sengupta A, Nundy S. The private health sector in India. BMJ 2005;331;1157-1158. 2.Hebert-Croteau N, Brisson J, Lemaire J et al. Investigating the correlation between Hospital of Primary Treatment and the Survival of Women with Breast Cancer. Cancer 2005;104:1343–8. Competing interests: Both the authors work in a public-funded tertiary cancer centre |
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BM Hegde, Retd. Vice Chancellor Mangalore-575004, India
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Dear Editor, Timely editorial, indeed. Even the politicians in India take pride in private hospitals encouraging medical tourism. Medicine has, of course, been taken to the market place these days and, consequently, market forces will have to act on the same. Making medicine a business could, in the long run, be counter productive. Business is for profit and profit at any cost. Very big money will have to have crime behind it. It might not be the type of crime that the mafia indulges in. One could either “manage” the tax payable to the government-a legal way of not paying taxes or under pay their employees and overprice their products. Not honouring their obligations to the government for customs duty waiver or not complying with the obligatory free treatment of poor patients in return for all the perks enjoyed by the corporate hospitals could also be included here. Medicalising human life is an obvious fall out of this kind of development in corporate medicine. In today’s scenario any one who goes for a routine check up becomes a patient needing intervention since we have a defective definition of “normality” with inbuilt false positives in medicine. There will be no “well” human being at this rate in future. Routine screening of the apparently healthy has become a big industry. In a country like India this makes sense. Anything can be sold as a risk factor these days. Large hoardings in metropolitan cities proclaim that killer diseases like diabetes and hypertension are going to annihilate Indians in the near future. Soon our “stars” will be there to advertise these claims. This makes very good business for the private sector medical industry. Clinical research organizations are another new addition to the burgeoning medical industry in India. These are the middlemen who get drug trials done in Indian hospitals for multinationals. “Informed” consent becomes very easy here, thanks to the gullible poor patients who still have faith in their doctors. Fee splitting is another menace that has crept in and would only increase as the competition gets stiffer. Be that as it may, India needs clean drinking water for its masses, a smoke free home with a roof over their heads, three square meals a day uncontaminated with animal and/ or human excreta and toilets for every house to avoid the ravages of hookworms. This coupled with economic empowerment of village women and compulsory primary education for the female child should make India healthy and wealthy. Let us remember that when doctors went on strike in Israel recently death and disability in the country went down significantly only to go back to the original levels after the doctors came back to work, thanks to the morticians’ intervention with the government on doctors’ behalf! Yours ever, bmhegde Competing interests: None declared |
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Dr Milind Karale, Specialist Registrar in Psychiatry Adrian House, Fulbourn Hospital, Cambridge. CB 1 5EF
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Sengupta and Nandi write that the solo practitioners and small hospitals are faced with competing the big corporate hospitals for survival. It is sad that the concept of family doctor is soon disappearing in India and so is the trust in the medical profession. A common man approaches the private sector with scepticism of unnecessary investigations, over prescribing and financial exploitation. On the other hand, government services are unpopular due to long waiting periods, arrogant attitude of the staff and non availability of the medicines1. A common citizen has tilting towards the private sector, but it is often at the cost of incurring financial debts. In such a scenario, medical tourism can be effectively used to improve the infrastructure of the government hospitals and health services. This can be achieved by compulsory diversion of a small but fixed percentage of the medical tourism revenue to the government sector. Kamran Abbasi writes that the government initiatives in healthcare are unsustainable because the loan monies are for a specific period and are unsustainable2. A steady diversion from the medical tourism revenue may contribute towards sustaining these projects and making the government sector more acceptable and approachable to the Indian public. References 1.G Ananthakrishnan . Info change News. June 2005http://www.infochangeindia.org/agenda2_08.jsp 2.Kamran Abbasi . Focus on South Asia –II : India and Pakistan . BMJ 1999; 318: 1132-1135. Competing interests: None declared |
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Peter D De Mello, Retired Engineer 1208 Geneva, Switzerland
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Instead of curbing Health Tourism to India, it would be preferable to ensure that Health Tourists contribute directly to help the many poor in India who do not always have access to "special" medical treatment. All Health Tourists could pay 10% of their hospital bills to a "Health Fund for the Poor". This is not an excessive demand.In Switzerland the cost of cataract surgery is €3500 for each eye. In India the cost is approx 1/10 or €350 for the same operation.The cost of a cataract operation in rural India is about €35, a sum which is unaffordable for the many poor ("Seeing is beliving" BBC documentary presented by John Major).Heath Tourism is a unique chance for India, we should turn it into a springboard for health improvement in rural India, Competing interests: None declared |
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Dr. Bichitrovanu Sarkar, Senior House Officer in Paediatrics Colchester General Hospital, CO4 5JL
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As foreigners keep flying into India for treatment, they are bringing money to spend in India as well. This in the long term will boost India's economy, and once money keeps rolling in and India's economy flourishes, the living condition of the general population will improve. Besides, as people get to see that patients are coming from UK and USA to get treated in India, Indians will stop going abroad for their own treatment, and may be in 10 yrs time there will be no need to go abroad for higher medical training as well, as more and more sophisticated facilities become available in India along with training opportunities. The poor do not go to private hospitals in any part of the world. They rely on the state run hospitals. And in order to provide good medical care in state hospitals, there needs to be adequate funding which can only be possible if the government has money to spend. Just like BPO (Business Personnel Outsourcing) this kind of health tourism is a revenue earner for India. We cannot expect private health sector to run on charity. And also to do charity, you need funds. If someone has invested money, he is looking for profit, whatever may be his declared intention. I think it is better to make the profit out of people who can afford to pay it rather than people who cannot afford. Foreigners who are coming to India for treatment are coming here for their own benefit. It saves them money and saves them time. They do not want to go bankrupt by going private in their own country and they do not want to wait on a public sector waiting list until a time they will never need the treatment anymore. I see nothing wrong if some private hospitals helps India earn foreign exchange so that funding is generated for the government to spend on the public health sector. One of the ways of increasing India’s foreign exchange reserve is to siphon money from outside. Just like trade, this is another way of siphoning that money into India. And these hospitals are providing satisfactory service to its foreigner patients so that the chain is perpetuated. People would not come from abroad if they donot get the proper care in India. Most of the problems in India including that of corruption is because of poverty, and the only way India can get rid of this curse is by earning more. I think instead of discouraging these hospitals from acquiring foreigner patients, I think we should encourage the Indian Government to make the most out of it and use the revenue so generated in providing better medical care to the poor through its public health sector. Competing interests: None declared |
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Sanjay Bhattacharya, Specialist Registrar in Virology Health Protection Agency, Heart of England NHS Trust, Basumita Chakraborti
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Editor, Congratulations to Sengupta and Nundy for the extremely topical and important article on Medical Tourism to India.(1) However, although having read the article with great interest we would like to differ with the authors on the overall impact of medical tourism in India and its relevance to the UK. Medical or health tourism to India from UK and other industrialised countries will help break the scientific and psychological taboos that exist in western mindset that third world or developing nations cannot provide health care comparable to first world standards. The process will undoubtedly generate valuable foreign exchange resources and be a positive boost for the Indian economy. The NHS is obsessed and rightly so about quality control, quality assurance and accreditation. These concepts are however not in practice in most Indian health establishments. If India is to exist as a long term medical tourism destination then it has to incorporate these ideas into its daily working practice. This will no doubt improve the standards of diagnostic services and therapeutic practices in India. Moreover, India is not the only developing country which is resorting to such practices. Various other nations in South America, South East Asia, Middle East and even in continental Europe are looking forward to the concept health tourism as an economic option. So if India does not take it up some one else will. Medical tourism as a idea already exists internally in India. Hundreds of thousands of people from less developed areas of India are forced to travel large distances in extremely difficult conditions to cities within India with better medical facilities in New Delhi, Chennai, Vellore, Mumbai, Kolkata and Bangalore. Therefore the idea of international movement of people and persons for heath care is just an extension of the same idea at a global level. This phenomenon if executed with efficiency is likely to improve infrastructure facilities such as roads, airports, hotels and communications network. Obviously in an ideal world there cannot be and there should not be two standards of health care- world class services for the foreign health tourists and substandard services for native Indians. Therefore, the focus should be to remove this disparity through increased health allocation in public health care, and allocation of a proportion of profits generated through medical tourism to develop health care for Indians. Such provisions should not only remain in paper but need to be implemented and enforced in practice. From UK’s perspective medical tourism to India or to any country which provides cheap, efficient, safe and rapid service is in the interest of those people who cannot afford expensive private health care in the UK. It is also good for community feelings and greater social integration as south Asians form the largest ethnic minority group in Britain. Increased interaction through travel, health care and tourism can only reinforce this relationship. It may also help reduce the so called North-South and East-West divide that exist in our social and economic interactions. Moreover, people in the UK have a right to decide which system of health care they choose to use. Considering the agonisingly long waiting list of NHS hospitals health tourism may provide low cost alternative to some of the financial and health worries within the NHS. Many Indian doctors trained in the UK or the USA are keen to return to their home land and be of some use to their country. Health tourism provides an opportunity for these professionals to come nearer to their roots. It would also be an effective measure to reverse the brain drain that is manifested through the migration of highly skilled and qualified professionals to developed countries for better job and career prospects. The additional benefit would be that parents and dependents of these health care workers who would have otherwise migrated to developed countries can stay in India with their relatives. Last but not the least, after the introduction of the foundation programme for the junior doctors in the UK getting a job in the NHS has become increasing arduous and frustrating experience. A growth in the health tourism industry in India may provide new employment opportunities in India for countless jobless doctors from the subcontinent who although having the requisite skills and the qualifications face an uncertain professional future. Dr. Sanjay Bhattacharya,
Dr. Basumita Chakraborti,
Reference: 1. Sengupta A and Nundy S. The private health sector in India. BMJ 2005; 331: 1157-58. Corresponding author: Dr. Sanjay Bhattacharya, Specialist Registrar in Virology, Health Protection Agency, Heart of England NHS Trust, Birmingham, B9 5SS. UK. Email: drsanjay1970@hotmail.com Competing interests: Sanjay Bhattacharya was trained in North Medical College, Darjeeling and JIPMER Pondicherry in India, and works in the NHS, UK. Basumita Chakraborti was trained in JIPMER Pondicherry and has worked in Northern Ireland till recently. |
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Tarun Durga, SHO Oncology and Pallative Care University Hospitals Coventry and Warwickshire,Walsgrave Hospital,Coventry,CV2 2DX
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The article on private health care appears to be giving a distorted view about its contribution to Indian Health care. It lacks objectivity. In the mid-1980s, India used to spend $40 million a year sending heart patients outside. But today, we have overseas patient’s coming to India for their treatment. It’s a great reversal and it happened because of our excellent doctors and private sector funding. I will illustrate a case example of one single private hospital in India”Escort Heart Institute’’.It is now one of the largest heart institutes in the world. It caters to over 4,000 surgeries, 10,000 angiographies and 3,000 angioplasties every year. Not only that, it have one of the best outcomes: 0.8 per cent mortality and 0.3 per cent infection rate, which is better than anybody else in the world(1). The Indian healthcare market is INR15 billion and growing at over 30 per cent every year. A recent CII-McKinsey study on healthcare says medical tourism alone can contribute $ 1-2 billion additional revenue for private tertiary hospitals by 2012, and will account for 3-5 per cent of the total healthcare delivery market(2). The benefit to tourism industry alone could be of the order of $30 million. Is it bad to earn foreign exchange? What is the harm in promoting medical tourism if it brings money to the country? The reasons why doctors move to private-sectors/abroad are very well known to everyone. India ranks as one of the most corrupt nations in UNDP reports(3). It is not without reason. The state hospitals have continual political and bureaucratic interference. The state hospitals have become black holes for the little funds invested. Fund infusions without proper and effective utilization will do no good to the State health care. I believe private sector is utilizing Funds and investments in an efficient mannar.No wonder 80% of outpatient attendances are in the private sector. I don't think beggars are choosers. When the government spends so little on health, it is better that brilliant doctors move to private sector or abroad rather than lose their skills in Indian state sector hospitals. 30 years ago during the socialist/communist regimes these views would have found ideological support but they wouldn’t have done any good. No amount of charity/retoric can substitute sound policies. I believe that private sector in health should be encouraged with simultaneous investments and reform in government sector. Both are equally important and should be complimentary. India still has one of the highest Infant mortalities and lots of deaths to communicable diseases. We don’t need tertiary hospitals and super specialist for treating the common ailments. A health worker costing fraction of a doctor can do the same job. The Increasing role of private sector in Tertiary care can help release precious funds for primary health care, cancer screening programmes, immunization, fighting malnutrition and proving safe portable drinking water. All over the world the role of private enterprise in health sector is being increasingly recognized. Even In UK which has an excellent well organized State funded health care delivery system need for private involvement is felt. No state can provide free universal health care .It is good idea but economically unviable. The rising cost of health care makes it imperative to have a combined approach People will need to move to insurance in due course of time. Indians as a population take health for granted. Change in mindsets is important. There are no short cuts to achieve excellence and health is no different. 1.http://www.indianexpress.com/full_story.php?content_id=79746 2.http://www.expresshealthcaremgmt.com/20050131/medicaltourism01.shtml http://www.unodc.org/unodc/event_2004-12-09_1_resource_guide.html Competing interests: Worked as Senior Registrar for 3years In Radiation Oncology AIIMS (GOVERNMENT Hospital)Delhi & FOR 4 YEARS at Safdarjung Hospital,Delhi(GOVERNMENT Hospital) |
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Shyamal Bagchee, Professor, Univ of Alberta Edmonton, AB, Canada T6G 2E5
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I have read with interest not only the entire article by Drs. Sengupta and Nundy, and the press reactions to it in India, but also the responses posted in BMJ so far. I need to point out to those who still believe in the much-discredited "trickle down" effects of money supply, that in the prevalent Indian system rarely allows the government to collect legitimate tax dues from the rich and the privileged. Therefore and especially, there cannot be even the smallest hope of any public good coming of medical tourism in India, no matter how profitable it might be to the service providers.
The fact that the state medical machinery so miserably fails in India--and similar systems do only marginally better in UK or the United States--has to do with the simple reality that the wealthy and the influential sections of the public have no interest in it. In the absence of the country's powerful folks' direct dependence on a healthy public system there can be only the dimmest hope for improvement. One need hardly over emphasize the obvious reality that the opinions and self-interests of the influential and the wealthy always sway government policies and priorities. The only solution is a single level, universal health care system with no individual either unqualified for it nor exempt from it. If the privileged section of the population is still unsatisfied with the national arrangement, it can always buy services from commercial providers outside of the country--as many such Indians even now do. Having lived in Canada long enough to know what it was like before our one-payer health system--warts and all-came into existence, I know too well what the other options are like. truly,
Competing interests: None declared |
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Rajan TD, Consultant Skin & Sex Transm Diseases, Andheri 0091-22-56982747 CMPH Medical College, Mumbai, India
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Sengupta and Nundy deserve to be congratulated for their brilliant analysis which has been playing on everyone's minds lately. However the two issues cannot be muddled together. We cannot wait for potable drinking water and electricity to reach every village before we design and build rockets! Development in different fields should proceed simultaneously and this fact should be borne in mind in the healthcare industry as well. Foreign exchange earned by medical tourism will certainly boost our economy which will in turn raise the standard of health care systems. What is needed is a systematic approach to make sure that a parts of the funds earned is channelled to primary health care. Therefore raising the allocation in the budget for health is definitely called for but not at the cost of a new source of national income. Competing interests: None declared |
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Omendra Narayan, Locum SHO Paediatrics Walsall Hospitals NHS Trust, UK. WS2 9PS
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Dr Nundy and Mr Sengupta have written a very enlightening article on the current trend for medical tourism and the practices in developing countries like India and other South East Asian countries. To be very frank the current state (of Population explosion, malpractices, unemployment and poverty) in which India is can only be amended if everyone realizes their self importance and try to contribute rather than cribbing on Government or other Private sectors if they are contributing in someway. Yes I definitely agree that Government should start a more structured health care system and spend more on basic needs of human i.e. health care and education rather than sectors like defence which we hardly need. The proper channelization of economy is definitely going to be of help to mass so lets stop passing remarks on private sector and rather urge the goverment to inculcate the good things from private health care. We (Indians) have a symbiotic relationship with world, no one is selfish, private hospitals in India are providing a good healthcare equivalent to developed nations like UK & USA, and this is why they are attracting global patients. So lets encourage them (Private Hospitals) and urge the government to improve the Public healthcare system simultaneously by promoting Health Education and taking out a bigger fraction of its GDP for health. To summarize let's be a part and parcel of the new emerging health care of India by some contribution rather than awaiting for help distantly. Competing interests: None declared |
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BIJU BASIL, Resident Philadelphia, PA 19067, USA, MAJU MATHEWS
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The authors of the article titled "The private health sector in India" have taken a very negative view of Government of India (GOI) encouraging "medical tourism"(1). The GOI is not spending any money to actively subsidize these so called five star hospitals. The encouragement of "medical tourism" is not at the expense of the amount GOI spends on public health sector, although the GOI could and should spend much more than 0.9% of the Gross Domestic Product (GDP) it spends now. The authors have reported that public spending on health care by GOI has declined from 1.3% of the GDP in 1991 to 0.9% of the GDP now. This is not because the GOI has decreased the amount it spends on health, but because of the fact that India's GDP has been increasing at 7% per year for the past few years (2). In fact, as the authors concede in this article, the GOI has increased the amount it spends on public health. It is a fact that a large percentage of patients have to pay bribes to see doctors at public hospitals. For some reason best known to themselves, these doctors don't consider it as bribe and call it consultation fees and sees nothing wrong in that practice. The GOI needs to regulate these practices better. It would also be helpful if the GOI increase the salary they pay the physicians in their payroll. Successive governments in India have encouraged the growth of private sector in health care industry. India with a population of close to 1.1 billion people cannot be expected to and cannot afford to provide public heath care for all. If the GOI attempts to do that the GOI will have to spend tens of billions of dollars each year. As seen in some other parts of the world, nationalized health system is not a panacea for all. This can at best lead to substandard health care and longer waiting times for essential service. As Canadian Chief Justice, Beverly McLachlin wrote in a recent case "Access to a waiting list is not access to health care" (3). India would benefit from a judicious mix of both public sector and private sector in health care industry. The GOI should meet the basic needs of the poor people, who will never be able to afford the health care provided by the private sector and increase the amount it spends on preventive health care. The hospitals in private sector in India are comparable to the best in any part of the world. Too much regulation can lead to bureaucratic delays and corruption. It will also discourage people from starting such hospitals in India. The private sector hospitals with state of art technology and higher salaries are able to retain many brilliant physicians, who otherwise would have left the shores of India for better working conditions and monetary gain. These so called five star hospitals provide employment to thousands of people, and as stated in the article is expected to bring in a billion dollar business in medical tourism to India. The authors also calls to impose greater social accountability on private sector and to impose conditions that a certain proportion of private services be available to the poor. The authors seem to forget the basic premise on which anybody starts an enterprise, which is profit. Any measure that cuts the bottom line is going to have a deleterious effect on the growth of any industry, health care is no exception. References: 1. Amit Sengupta, Samiran Nundy. The private health sector in India. BMJ 2005;331:1157-1158. 2. Democracy's drawbacks. The Economist. Oct 27 2005 3. Ethan Kass. Canada Is No Model. Psychiatr News 2005 40: (19) 30 Competing interests: None declared |
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Abhijit M Bal, Specialist Registrar Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN
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I read with interest the editorial on private health sector in India (1). There is no denying the fact that the private health sector suffers from many drawbacks. However, we must realize that if the private sector is a part of the problem, it is also a part of the solution. The health needs of a billion people simply cannot be managed by public sector in a country that lacks basic infrastructure. The public health sector needs a boost in investment so as to provide quality care to the patients and to preserve the morale of the staff. At the same time, it is only appropriate, and indeed desirable, if the private sector can shoulder some of the burden of the population’s health needs. The authorities need to regulate the health care delivery standards expected of the private sector instead of stymieing their profits by various unworkable means. On their part, the private health sector magnates must realize that there is often a thin line between profit and profiteering. Much can be achieved if both, the government and the private sector, uphold the sanctity of the line. References: 1. Sengupta A, Nundy S. The private health sector in India. BMJ 2005; 331: 1157-58. Competing interests: None declared |
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Dr Jayaraman Nambiar, Assosicate professor Manipal MAHE India
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The main reason behind the growth of increasing private care in India is the lack of proper infrastructure in the goverment sector.The goverment sector is rampant with corruption in India and patients nowadays feel that it's better to pay in private hospitals and get better care at private hospitals.Another reason is that many private hospitals nowadays give excellent care at affordable cost for the common man.In fact private health care in India is rpaidly growing and perhaps I feel that Indian private care in few years will challenge the best in the world. In fact many patients from developed countries like UK etc are coming increasingly to India for treatment. Competing interests: None declared |
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Amitava Bose, Hospital Consultant - Facility Panning and Equipment Planning 22
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The article by Sengupta and Nundy makes good reading though one fails to see any connect between the burgeoning private healthcare sector in India and the abysmal condition of the government healthcare system. It is unfair to say that private healthcare is growing at the cost of public healthcare. Let us place the blame where it ought to lay – the government’s insufficient spending on healthcare. As Jean Drieze & Amartya Sen point out in their book, India: Development & Participation, while public spending on healthcare has been steadily dropping, during the first half of the 1990’s, India’s defence budget grew at a modest rate of 1.5% p.a. in real terms. Since 1996-97, the defence budget has been growing at 10% p.a. in real terms. This sharp increase contrasts starkly with worldwide decrease during the 1990’s. Would it then not be appropriate to say that defence spending is growing at the cost of public healthcare? Patients will go wherever healthcare is available. If government hospitals in India do not provide it then Indian patients will go to private institutions. As patients from other countries come to India to avail private healthcare so do patients from eastern India go to south India for treatment at private institutions since these institutions are perceived to offer better treatment than their counterparts in eastern India. One or more of the respondents to the article have suggested the levying of a tax on hospital bills of foreign patients to be credited to a “fund for the poor” or diverting a portion of the revenue earned from medical tourism to the government to be spent on healthcare. This is ludicrous. Going by this analogy, patients from eastern India should then contribute to the coffers of the state governments in south India. Also, judging by the government’s penchant for defence expenditure, if a percentage of the revenue earned from medical tourism is to be given to a government fund, in all probability it will end in spending on defence. There is a common or popular belief that private hospitals in India make enormous sums of money by exorbitantly charging the poor patient who seeks treatment at a private hospital because government facilities are inadequate. Firstly, the private hospital being a commercial venture the promoter is entitled to his return on investment. He does not claim any altruistic motive, be it a nursing home set up by a private practitioner or a corporate hospital. It is naïve to expect these entities to provide social service in healthcare where the government, whose responsibility it is to do so, has chosen to abdicate its role. Secondly, one cannot deny the fact that private healthcare in India is expensive for the Indian patient. This is so for a number of reasons. 28% to 30% of the project cost of a 100-bed hospital and upwards relate to expenditure on medical equipment. This is a recurrent cost for hospitals as obsolescence in medical equipment is high and it is further aggravated by fact that most equipment in India is imported. Maintenance costs for these equipment are high. Also, most medical and surgical disposables used in critical care surgeries are imported. Contrary to what Sengupta and Nundy writes, medical equipment and disposables imported by hospitals into the country are subject to prevailing rates of duties. There are no concessions in duties or taxes. So, there is a common saying in private hospitals, “Spend in U.S. dollars and earn in Indian rupees”. Hence, private healthcare is there for those who can afford it. The moot point is what has happened to the government’s responsibility of providing healthcare and where are the pressure groups who can influence government spending in healthcare. Berating private healthcare for not assuming the government’s role in providing healthcare to its citizens is not the solution. Yours etc. Amitava Bose Hospital Consultant-Facility Panning and Equipment Planning Competing interests: I disagree that private healthcare in India is growing at the cost of public heathcare |
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DINESHKUMAR THANIGACHALAM, clinical observer AINTREE HOSPITALS,LIVERPOOL
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Dear Editor, First I congratulate the editorial board &authors for their timely publication. I completely agree with their views. But i want to stress the importance of medical education in India.India is the best place to learn medicine for its disease prevalence. No one could deny that even though private hospitals doctors were trained in UK/US, they learn their basics in India. It is time for them to repay the services to poor citizens. Private Hospitals should allote some percentage of their services for free to poor patients in need. Competing interests: None declared |
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E Suresh, Consultant Rheumatologist Kettering General Hospital, Rothwell Road, Kettering NN16 8UZ
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Firstly, I wonder why the authors decided to publish this article in the BMJ, which is not very widely read within India. Of course that it wouldn’t have made any difference to the practice there, even if it had been published in an Indian journal is a different matter altogether! But the reason why the authors decided to bash the Indian system of medical practice in a British journal is totally unclear to me. The only relevant issue to the British public is that they would pay a lot less for an operation even in any of the so-called five star hospitals in India, for the simple reason that the value of a pound is about 80 Indian rupees. But it is worth noting that a strong statutory body like the general medical council is non existent in India. So, what if something goes wrong? Who will follow up these patients after surgery? Although patients go to India at their own risk, do they realise that most of those doctors only possess Indian medical qualifications that are not recognised by the general medical council? Competing interests: None declared |
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VANI BADRISH KULHALLI, Consultant Psychiatrist Vile Parle East, Mumbai-57
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The article made interesting reading, but the authors are confusing many aspects which are inter related but not necessarily in a cause and effect relationship. For Example, it is overinclusive to say that private healthcare is cannabalising public healthcare. Fact is that for years all policies, rules and laws have been gradually amended by the GOI to suit interests of foreign practice and affluent classes, medical tourism is only another facet. While the media cries foul over migrating Doctors of all cadres, it is the GOI which has given an undertaking of 'surplus' in medical skills to enable overseas recruitment. The medical education is completely streamlined to acculturate young doctors to practice Western medicine in Western settings. Private medical enterprise suffers from real problems with sustainability. It is not only greed, but also need which drives the age-old conflict between commerce and medicine. With soaring land prices, equipment costs in foreign currency, labour-intesive business model and lenghty time to break-even; the average medical enterpreneur finds it difficult to qualify for loans, repay them and run the household. It will serve well for the GOI to stay away from either encouraging or discouraging the foreign patient enterprise. It should certainly not enter into treating foreign patients. Instead it should focus on its duty of providing proper preventive and primary healthcare and effectively play its regulatory role. In a perfect world the State should be responsible for the health of its citizens(own citizens first), because good care gets seriously jeopardised by commercial interests. Competing interests: None declared |
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Amitava Banerjee, Senior House Officer, General Medicine, John Radcliffe Hospital,, Oxford, UK
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I echo many of the points made already in other responses that this is an extremely timely analysis, but argue that the issue is grossly oversimplified in Sengupta and Nundy's article. I have three points to make: (1) India's private and public sectors are not suffering from unique problems; (2) particularly in terms of technological advances, the booming private industry can be benficial to public health; (3) a more complex analysis needs to include discussion of ethics, rights and the brain drain. Private healthcare is not so different to any corporate entity, in that, supply and demand are the two important determinants. There is a relatively good supply of skilled medical and ancilliary personnel (who are increasingly disillusioned with the public sector). There are supplies of existing medical technologies and the capacity to develop new technologies to compete with anywhere in the world. Within India, even before medical tourism, there has been demand for a system which offers "better" services. Therefore, towns in Kerala have some of the highest concentrations of radiological and investigative laboratries in the world. The demand from outside India has arisen because the quality of Indian private hospitals can be equal to anywhere in the world, at a much cheaper cost, AND the medical tourists are escaping from problems in their home countries. The problems with private medicine in India are seen in many developing countries, and also in richer nations. The problems of high health insurance costs, over-investigation, health disparities and lack of insurance coverage are also rife in the United States. In the UK, seen by many as the prototype for nationalised health systems, the private sector has increasingly played a role in all aspects of medicine in recent years, as the public sector cannot cope alone in an age of increasing demand from patients and doctors. Raising the amount of funding as a percentage of GDP is not necessarily the panacea for increasing the quality of health care. In the US, a massive 15% of GDP is spent on healthcare and still there are huge inefficiencies and disparities in the system. The problems of a "small bucket" and "lots of holes in the bucket" are not unique to India. Public health in India, a country of a billion people, is a huge challenge in every way, but "private healthcare" does not necessarily equal poor public health. It is poor management, corruption, bureaucracy and other inefficiencies which are bleeding the Indian public sector and damaging public health. The Aravind Eye Hospital in South India, described by C.K. Prahalad in his book "Fortune a the Bottom of the Pyramid", is an example of an innovative method of delivering affordable health care to the rural poor whilst maintaining quality and competitiveness within the urban Indian market. The Aravind Eye Hospital has established itself as one of the premier training institutions for ophthalmology internationally. This remarkable venture was founded by Dr. G. Venkataswamy in 1976. It began as an eleven-bed hospital and is now a chain of 7 hospitals across South India with over 4000 beds. By 2004 it had screened over 5 million patients and performed 2,225,225 cataract surgeries. Almost 70% of all surgeries are performed free of charge (1). The Kalam-Raju stent, India’s first indigenous stent developed through missile technology by India’s current President Abdul Kalam and Dr B. Somaraju, a Hyderabadi cardiologist, has brought down the cost of basic angioplasty significantly, resulting in cheaper modern medical care for the poorer sections of the community. The same group has also developed India's first indigenous prototype cardiac catheterisation laboratory at Care Hospital in Hyderabad, which should further reduce the cost of treatment to a large extent (2). We should not forget that it was the massive growth of the Indian generic pharmaceutical industry which facilitated supply of antiretroviral drugs to one-third of developing countries (3). Therefore, India's private sector can benefit public health, within India and globally. Finally, as well as the universal right to (public) health, doctors and patients have a right to move freely. The movement of the former has led to the brain drain over several decades, and the movement of the latter has led to medical tourism. Both of these movements need to be controlled so that public health is not compromised, and is actually ameliorated. 1. Prahalad C.K. The Fortune at the Bottom of the Pyramid 2. Banerjee A and Rao B. Integrating Treatment and Prevention - Ischaemic Heart Disease in India. www.procor.org 3.Will the lifeline of affordable medicines to poor countries be cut? Consequences of medicines patenting in India. MSF Feb 2005 Competing interests: None declared |
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Dinesh Singhal, Consultant, Department of Surgical Gastroenterology Sir Ganga Ram Hospital, Delhi
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The rapid growth of private health care and decay in the public health institutions has created a situation where the kind of health care an individual gets depends on what he or she can afford! Thus while an affluent person can get a cancer operation or coronary bypass or even a live related liver transplantation almost overnight, the economically backward sections of the society may have to wait for months for a simple cancer operation or even die while on the waiting list – hardly a flattering situation for a country that has the word ‘Socialist’ in its preamble. The health care planners in India seem to have had scant respect for the fabled ‘common man’. In this regards, we have a lot to learn from the experience of other countries. Having worked in the Netherlands recently, I believe the model of the ‘Socialist’ health sector needs to be studied more closely. The Dutch system caters equally to the health care needs of the underprivileged sections and the rich. It is true that in a country like India, government alone cannot provide for health care of the entire population which now numbers over a billion. The experience of the city- state of Singapore is noteworthy. There the government’s share of health spending on an individual depends on his income – more is spent on the poor and less on the rich. These are just two examples – there may be many more from which we might learn… It is not that there have been no benefits after the growth of the private sector in India. The notable spin offs include quicker treatment, rapid introduction of the state-of-the-art technology, a clean environment, friendly staff and, most importantly, an accountability for work which is sadly lacking in the public healthcare system. There is an urgent need to evolve a suitable indigenous model to make at least a minimum level of care available to all Indians, regardless of their ability to pay for it. Dr Dinesh Singhal
Competing interests: None declared |
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Dr.Sumanth C Raman, Consultant Physician Chennai, India.
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Sengupta and Nundy need to be congratulated for having in their article, brought out the irony of a country that is unable to take care of the health of its own citizens wanting to take care of the health of the world. The argument that a focus on Medical Tourism does not in any way take away from spending and prioritizing on Public Health Care has been made by many who have responded. While this may be valid it still does not take away from the fact that the serious lobbying by the Private Operators has been a distraction to the Government in going about its work. When there is a constant debate on whether the State should hand over its healthcare facilities to the Private Sector and outsource its Healthcare Delivery and with the media ready to lap up the stories issued by the PR Departments of Private Hospitals on Medical Tourism it is difficult for the Govt.to reaffirm to an increasingly sceptic public that it needs to get its own house in order rather than sell out altogether. What about the money the Govt. has already spent(and is continuing to spend) in indirectly subsidizing Private Health Care? How many of the Free Tests that were to be done when the Duty Exemptions were given for import of Medical Equipment by Private Hospitals have actually been done for the poor? Why should the Government Medical Colleges train doctors and nurses charging fees that are ridiculously low and then not extract even a minimum number of years of service in return from them? Why are there no tariff slabs defined for expensive investigations to reduce the chances of profiteering? (A CT Scan of the same body area can cost anything from Rs.750/($17)- to Rs.7500/-($170) in the same city depending on the Hospital).Why are Licenses given to Private Medical Colleges without regard for their geographical proximity from one another and their ability to serve a larger populace? (Example: Pondicherry, a tiny state has 4 Medical Colleges within a distance of 25 kilometres of each other and another 3 are rumoured to be in the pipeline.)The list of questions is unending. For a majority of Indians a major illness in the family leads to financial ruin. Unwilling to risk treatment at the State run facilities the family spends its life savings and then borrows to the hilt to try to save the patient and admits him to a Private Hospital. Within a week or two the life savings and the borrowings are gone and for years together the family struggles mired in debt. As Doctors working in India all of us see such cases every day. Yet few of us ask the question-is this the only way? Can there not be a system where the State if not providing for affordable health care at least legislate to make health care in the private sector itself more affordable? Therein may lie one solution with the Govt. fixing tariffs for surgical procedures , investigations etc. after categorizing Hospitals into different tiers. One top tier could be left unregulated for the elite Hospitals and the wealthy among the public too. If the Govt. can fix the price for drugs, why not for tests and surgical procedures? The Private sector is bound to resist this fiercely but the State has a responsibility that it must fulfill. The lives of millions of Indians is at stake. Competing interests: None declared |
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KC Mahajan, Chairman, Department of Academics and Research Sir Ganga Ram Hospital, New Delhi 110060
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I congratulate Amit Sen Gupta and Samiran Nundy for bringing into focus the ills of the healthcare scenario in India, today. There is no denying the fact that independent India immediately after 1947 had an effective public health sector which provided adequate service to the poorer sections of society as well as the middle class. With the passage of time this sector has gradually undergone a steady deterioration despite large budgets and liberal contributions from foreign countries and international agencies.
The setting up of postgraduate institutes by Acts of Parliament which have complete autonomy and highly qualified faculty members recruited from the best available in the world as well as ample funds have not improved the plight of the common man. The work load of the doctors and incessant interference by politicians and bureaucrats has led to their goals of providing high quality health care to the poor, good medical training suitable to our country’s needs and research into Indian diseases being missed. The weaker sections of society are still no better off. This is also because with the passage of time the initial idealism has flagged, the targets and agendas have become diluted and the best professional talent in the institutes have frequently left to work abroad or join the private sector, mainly for fiscal reasons. Today the public sector and government have abandoned their leadership roles in health care as well as in the management of major railway accidents and other disasters. The infusion of mammoth funds into the public sector today, will not make an iota of difference. There is a total lack of accountability compounded by inadequate monitoring by the government. This lack of governance has led to suspect professional practices such as large scale pilfering of consumable items and the misappropriation of funds meant to provide service to the poor and the needy. This is the cancer which is eating into the vitals of the public health sector scenario. Only the will of the government agencies to stop these rapacious and marauding practices can prevent irretrievable damage. Corporate hospitals structured by industrial houses with their main motive of profit- making, who make little or no contribution to the health care of the weaker sections of society must not be allowed to secure government approval and support. Their functioning and how they came into existence has been outlined in great detail by Justice Qureshi whose voluminous report is gathering dust in the government archives. These corporate hospitals are not at all interested in academic medicine which provides the medical profession the wellspring to thrive, study, carry out research, discourse, evaluate, treat, learn and improve. Academic medicine which contributes to the overall progress in medicine and bringing down health care costs is totally ignored. On one major issue I completely disagree with the authors. Medical tourism should be encouraged and promoted. Community hospitals which are managed by doctors or even Trust hospitals in which doctors have a say are providing quality health care either free or at a highly subsidized price to the weaker sections of the society. They also service the more affluent section of society with competence and elan. These should use their facilities to attract medical tourists. The Govt. of India should ensure that a part of the revenue thus generated goes into a corpus for ensuring the health needs of the poor and indigent. Medical tourism will also help to further improve the skills of our doctors and push down the costs of health care for the public at large. Conclusion: The health care of a billion people cannot be provided adequately by the public sector alone. This will entail the commitment of massive funds, which the Indian exchequer can not afford. It is only appropriate, correct and necessary that the private sector shoulder some of the burden. The private sector stool stands on three legs 1. Quality 2. Affordability 3. Ethical practice with tight fiscal controls resulting in reasonable profit Profit making is not an ugly word but profiteering is: the sanctity of the dividing line must be maintained, never crossed, like the “Lakshman Rekha”. Competing interests: I am the Chairman of the Department of Academics and Research of a Trust Hospital. |
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