Recent events have shaken up the healthcare system in the country like never before. The entire private healthcare sector in Karnataka, ground to a halt with a strike triggered by the proposed amendments to the Karnataka Private Medical Establishments Act, as adopted from the central “Clinical Establishments Registration and Regulation) Act 2010”. Health being a state subject, the Central Act became a Directive Principle of State Policy rather than a law. States were expected to adopt the Act, or modify their own existing Acts. The uptake was very slow. Till date, 5 states and UT’s have adopted and implemented it. WB and Karnataka implemented modified versions, others have adopted but not implemented the Act. Unfortunately standard treatment guidelines to be promulgated under the Act were neglected both in awareness and implementation and totally unreasonable rules introduced; and the opportunity to stop irrational over-investigation, and over-treatment was lost.

  The Karnataka government created three main bones of contention. Whereas the chairperson of the regulatory committee in the central act was the D.G.H.S and a former HC judge in the WB act, in Karnataka it was the chief executive of the Zilla Panchayat, a politician. Jail terms up to 3years and fines from Rs 1-10 lakhs even for minor infringements were prescribed. Fees chargeable were fixed. How one equates the fees of a fresh graduate with that of a consultant with 30 years’ experience is beyond me. Private hospitals were obliged to treat accident and assault victims as emergencies “till they were stabilised” without recourse to any reimbursement; ignoring the Law Commissions recommendation of a central fund to cover costs in such contingencies so that medical establishments are not out of pocket and therefore do not hesitate to provide humanitarian assistance. Incidentally Goa does not have a CEA act and all attempts to do so in the last 15-20 years have ended in a “black hole” to quote the CM. One former CM’s irresponsible response to suggestions for such an act was: - “the more rules we have, the more they will be broken”. 

How did we ever reach such an abysmal state? There has been a total abdication of responsibilities by successive governments in matters of public health. No vote bank is affected by a failure of constitutional obligations in public health; and the doctors were convenient fall guys. The private sector accounted for 8% of hospitals in 1947; today the figure stands at 93% purely because for 70 years the health budget has ranged from 0.9 to 1.2% of GDP. Compare that with 8% in UK and 17% in the US. The vacuum created was filled by the private sector in spite of demonisation by the media. This government neglect now manifests as a total incapability to provide affordable equitable and accessible healthcare compounded by an absolute lack of regulation. Current attempts at regulation are more illogical political stunts rather than attempts to strengthening an impotent service.

A judgment last month by the Allahabad HC got it spot on. 5 doctors applied for VRS from the Provincial Medical Services in UP. The state government refused on the grounds that there was a scarcity of doctors in the state. The doctors filed a petition in the Allahabad HC which gave a ruling which severely castigated the government. “Efficiency should become the keyword in all activities involved in running hospitals so as to avoid frustrations of medical staff with inadequate infrastructure, non-working infrastructure and unsafe working environment.” The court observed that in every sphere of employment, a government job is a much sought after entity. I would add often commanding hefty “premiums”. The only exception is in health care. Vacancies exist by the thousands. For example in Gorakhpur 7328 posts have been vacant for years. In Maharashtra, inviting doctors to quote their salary failed to attract them to rural PHCs’. Even in a small state like Goa, the vacancies cross a thousand. Why? In the US, surveys have shown that young doctors prefer the security of a salaried job to the insecurity of independent practice. The answer in India is lies in the state of our public healthcare facilities.

 From the time of the Alma Ata declaration on “Health for All” in 1978 laying down the principles of the PHC concept, there has been gross neglect of these PHCs’. Consider the ground reality today. The candidate for appointment to a PHC is likely to be young with possibly a wife and young children. He is expected to serve in a unit where neither water nor electricity are assured; forget about adequate equipment, schools and recreation centers. And now we have the added threat of physical assaults and media trials. Doctors even in urban hospitals have been shot at, skulls fractured, blinded and limbs broken because of perceived negligence. I am not aware of a single case where the assaulted doctor was proven to be negligent. And punishment?  In most cases political patronage ensures bail, dragging the case out ad nauseum in an impotent judicial system. Is it any wonder that the country is short of 0.6 million doctors today and expected to touch 2.07 million by 2030? Medical seats go a begging in private colleges, and graduates refuse to subject themselves to such inhuman conditions. The field is then left wide open to the “jhola chap” brigade. It is another story that these “doctors” are a result of the largesse of qualified practitioners themselves as a survey by former health secretary, Shailaja Chandra revealed. Attempts at regulation swing from irrational as in the Karnataka case to downright stupid as in the draft “Medical Treatment of Terminally Ill Patients (protection of patients and medical practitioners) Bill”. Such a bill, for example, properly drafted would have avoided the regrettable incidents at Max and other hospitals.

 One can’t help asking: how bad do things have to get before they start getting better. And how long will doctors continue to be made scapegoats for the failure of our “leaders”?

(The writer is a founder member of the Voluntary Health Association of Goa).