Privatisation of health care: new ethical dilemmas
Surinder Jindal discusses some of the complexities arising from new trends in health care
Increasing economic liberalisation and privatisation have affected health care as much as they have affected many other social and administrative systems, perhaps even more so. Though the changes are global, in India, the shift seems to have happened overnight, and public health services have been overwhelmed all of a sudden.
This was inevitable. How can one expect proper health care from a state which is unable to guarantee its people clean water, food and housing? Infact, very few countries can afford to provide their citizens comprehensive health care. Wherever state-managed care is free it is nominal – or there are “hidden” costs to the user. Today the majority of us must take care of our own food, clothing, shelter and health needs.
State responsibility in health care
There are three main elements of health care: prevention, treatment and rehabilitation. Prevention of disease is both a personal and a state obligation. In fact, the state has enormous stakes in the maintenance of healthy and relatively disease-free society. It is committed to providing a good and clean environment, water supply, family and social welfare services, vaccination and health advice.
Individuals, on the other hand, may choose to abide by the state’s laws and follow general health guidelines, in their own interests. Private and voluntary organistaions have an important role to play, depending on their specific aims and objectives.
It is largely curative and rehabilitative medicine which is getting privatised, and rightly so. Such services are not only costly but highly individualised and time-consuming as well. Recent advances have expanded vistas in health care, raising people’s expectations. They can not only stay healthier but also live longer. Body imaging and scanning procedures, endoscopic surgery and screening examinations have helped diagnose diseases earlier and with greater precision. New drugs and interventions have modified the natural histories of most diseases. Both morbidity and mortality have decreased.
Newer methodologies have also helped rehabilitate even the most severely disabled, including those with chronic and systemic diseases. People with gross respiratory, cardiac, renal or cerebral insufficiencies are now able to live more meaningful, useful and enjoyable lives.
Better services, more choices
People are no longer satisfied with general panaceas for their ills. Some patients may want a quick fix if possible, but a large number prefer to have their condition diagnosed and treated with the help of all available technology. Moreover, this is both scientifically and legally required.
Individualised care is obviously easier in private than in government institutions. One can choose both the treating doctor and the time and place of treatment. In certain conditions the patient may want to choose the method of treatment as well. This is especially true for surgery where more than onc eoption is available, such as between endoscopic and open removal of a gall bladder. It can be even more critical when there could be a choice of a life support device such as a pace maker.
A privatised system can also provide better nursing and allied services. It can provide better facilities for attendants and other care-givers. Patients and their relatives are not pushed around, neglected and ignored. Such care may also provide patients with a choice of convenient timings, treatments and costs, though these factors can be limited in both private and public sector settings.
Thus, privatisation has helped improve health services – their type, scope, quality and consequences.
The price of privatisation
Privatisation leads to steep hike in health expenditures, attributable to the increased costs of medical consultations, drugs and devices, medical tests and hospitalisation. Everybody involved has to earn; private medical practice is a profession, not just a public service.
Because of the pressure to make a profit, many private doctors, hospitals and diagnostic centres promote uncalled-for investigations and treatment in order to recover their initial investment. So services with limited value will be popularised and promoted to many people – whether or not they need it.
This is true for the simple ultrasound scanner, endoscopy centre and test laboratory as well as the more costly and sophisticated lithotripsy, CT and MR imaging, balloon angioplasty and transplant. Every test and treatment must be marketed like a commercial consumer product. This is done y individuals as well as big commercial organisations. Newly developed drugs, test kits or instruments are promoted aggressively. All kinds of methods are used to prove that the product at hand is superior to other, and almost indispensable in itself. The strategy succeeds at the cost of rational, ethical practice and patient care.
Points of concern
I will not make value judgements, only raise certain points that concern all of us. The most important is the availability of health care. The economically deprived are bound to suffer in a private health system.
The public sector provides limited services and charity encourages inefficiency and dependency. But knowing this does not help one overcome a feeling of helplessness and guilt when seeing a needy patient with a curable illness suffering because of the absence of a sincere social welfare system.
Privatisation has also encouraged unhealthy competition among the groups involved, since the objective is not only to earn, but to earn more than others.
Privatisation leads to the relative neglect of problems from which there is little to earn. Everyone including the state is interested in setting up commercially viable units. National preventive programmes get neglected.
There is also an undue stress on procedure-oriented medicine. Well-considered, comprehensive advice is bypassed for a computerised laboratory test, resulting in the loss of the human touch.
Effect on medical education
The general decline in standards of medical education and research in most Indian medical colleges can be partly attributed to privatisation. Busy clinicians and hospitals see little reason to invest their time and money in education.
Running private medical colleges is lucrative, but the standards of education have fallen, especially at the undergraduate level since the primary motive is to make money. The basic MBBS diploma is devalued today. An MBBS doctors is reduced to doing the work of a village level health worker or being a postgraduate-in-waiting.
I believe this is at least partly due to privatisation, because private practitioners and institutions almost always prefer practice to teaching and training.
Research, a high-cost investment with poor or uncertain returns, is largely the domain of a few institutions and pharmaceutical companies. Most medical research in India is unoriginal, rarely resulting in improved techniques or therapies.
Privatisation has undoubtedly improved the quality of health care, and widened its scope and availability. And private health services will continue to flourish, since they provide curative and rehabilitative services that the state does not provide. But privatisation has resulted in a number of problems hitherto alien to Indian society. Promoting health care as a consumer service and product is both unhealthy and risky.
It is high time we ponder this worsening situation and take remedial steps.