Given their expertise at playing to the gallery, the recent series of attacks by politicians on various aspects of healthcare in this country were hardly surprising or unexpected. The first salvo came from the PM Narendra Modi during his Phulpur rally in UP. He declared his mistrust of medical practitioners in the rational use of stents in patients and lauded his government’s decision to cap the pricing of stents. This was no achievement; it was in fact an example of the judiciary holding the government accountable for its negligence of healthcare and forcing its hand.
In response to a writ petition by Birender Sangwan an order was passed by the Division Bench of the Delhi H.C. (W.P.(C) No.1772/2015) dated 25 February, 2015 to list coronary stents as essential medicines. The court directed it be treated as a representation to be disposed of within three months. The government sat on its hands resulting in a contempt petition being filed alleging willful disobedience of the order. Faced with this contempt charge, the government was forced to implement its own notification of 19th July 2016, and a fresh order passed on 13th February 2017. This issue of overpricing can be extended to a whole host of products. Take any drug marketed by multiple companies and you will find a completely unjustifiable price variation of 50-100%. A syringe that is manufactured in India and exported for a price of Rs 2, is sold in India for Rs 10! Such variations have nothing to do with patents or licensing and applies to virtually all implants, not just stents.
The accusation of irrational use bears reflection. Research has alleged that a significant percentage of stents inserted are unnecessary; and they certainly appear to be. But over-treatment goes hand-in-hand with any system that operates in a fee-for-service mode. Consultants are known to be given targets in corporate hospitals in lieu of their appointments; which can only be met with over treating and over investigating the patient. A patient referred elsewhere from Goa with all the necessary tests done and a firm diagnosis made, invariably has them repeated at the referral center. The question is how such a situation came about. It is a dismal reflection of the governments’ negligence of healthcare and its reliance on the private sector to make up the deficit.
The ever opportunistic Maneka Gandhi, declared that doctors should be named and shamed for unnecessary caesarean sections done with the doctors’ pocket in mind rather than the patients’ interests. The media promptly took it up. The WHO was quoted as saying that a C-section rate above 10-15% was unacceptable. Rates are indeed higher than this figure; 58% in Telangana and 34.1% in Tamil Nadu when both government and private hospitals are taken together. The rates in private hospitals alone are as high as 70.9%in West Bengal and 74.9% in Telangana. The question that both Maneka Gandhi and the media have ignored is: how and who decides what an acceptable rate is and what does this figure of 10-15% refer to?
The WHO certainly does not recommend a specific rate for countries to achieve at population level. What the WHO paper does state is that as countries increase their C-section rates up to 10%, maternal and neonatal mortality decrease. However, rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. Furthermore, mortality is not the only outcome to consider; “but lack of data prevented the inclusion of these and other outcomes” in the WHO analysis. If a hospital is a major referral center and receives a proportionately larger number of complicated cases, it will naturally reflect a higher C-section rate. The point being that nowhere is there a prescribed rate for C-sections; it depends on variables like local population, culture and geopolitical boundaries. If Mrs Gandhi really means business as opposed to scoring political points by using the medical profession as “whipping boys” she should seriously implement tools like the Robson classification proposed by the WHO, to initiate proper scientific studies to compare C-Section rates before shooting her mouth off; or stick to animal concerns.
Mamata Banerjee then joined the bandwagon and went to the extent of ramming through the West Bengal assembly without debate, a draconian revised version of the Clinical Establishments Act (CEA) largely based on the assumption that private hospitals were negligent and over charging patients. Interestingly an average of only 4% of a hospital bill goes to the doctor who has to bear the brunt of accusations of overcharging and assault by relatives. The precipitating incident was a hospital providing emergency treatment to an accident victim. The real problem is a myopically drafted CEA which mandates that a hospital is obliged to provide emergency treatment (the new W.B. bill specifies accidents, acid attacks and rape). What is ignored is the Law Commission’s recommendations to the government years ago to make provisions for the treating hospital to recover the costs of such emergency treatment. Who will pay for resuscitating a serious accident victim, which can easily go into lakhs in a few days? The government cannot simply walk away from its social responsibilities. If it cannot provide the infrastructure for dealing with such emergencies, it should at least put in place mechanisms to reimburse those who do. But can one really expect rationality from such an impulsive, intemperate and volatile politician?
Capping freebies to doctors to Rs 1000 was a commendable action. The MCI has had penalties laid down for accepting freebies for some years. The pharma companies cleverly circumvented this with cash payments or funding associations rather than individuals. The new rule capping freebies in any form or manner was issued under the Uniform Code for Pharmaceutical Marketing Practices and therefore applicable universally. Undoubtedly there are black sheep within the profession. However to generalize and use doctors as whipping boys for policy deficiencies, is equally deplorable.
(The writer is a founder member of the Voluntary Health Association of Goa.)
