IMPROVING CONSUMER INTERFACE OF PRIVATE HEALTHCARE: REGULATING THE PRIVATE HEALTH SECTOR

Center for Enquiry into Health and Allied Themes (CEHAT)

Growth of the Private Health Sector in India

In 1947, the private health sector provided only 5-10 per cent of total patient care (Sengupta 2005) but in 2004 it is 78 per cent in the rural areas and 81 per cent in the urban areas (MoHFW 2007).

India’s public spending on health, after increasing between 1950–51 and 1985–86, stagnated during 1995–2005.It was down to 0·95 per cent of the GDP in 2005.

In 2004–05, government expenditure (including external support) accounted for 22 per cent of total health and private spending in 2004–05 accounted for 78 per cent of the total spending on health (Shivakumar 2011).

Public health expenditures across countries

Life Expectancy

Total Health Expenditure as % of GDP

Public health expenditure as % of total

U-5 mortality

Male Female India 5.2 17.2 95 59.6 61.2 China 2.7 24.9 43 68.1 71.3 Sri Lanka 3.0 45.4 19 65.8 73.4 Malaysia 2.4 57.6 14 67.6 69.9 Korea 6.7 37.8 14 69.2 76.3

SHARE OF HEALTH EXPENDITURE

Private Out-of-pocket

85%

Private In-vestment/ Insurance

2%Public-States

10%

Public-Centre3%

Source: (MoFHW 2007 NSSO)

Hospitalsation Cases: Govt/ Private (Percentage)

NSSO Rounds

Rural Urban

  Govt Private Govt Private

42nd

(86-87)59.7 40.3 60.3 39.7

52nd

(95-96)43.8 56.2 43.1 56.9

60th

(2004)41.7 58.3 38.2 61.8

Trends in Hospitalisation

Public-Private Share of Care

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Outpatient Care

Hospitalization

Institutional Deliveries

Antenatal Care

Immunizations

Public-Private Sector Shares

Private Public

Characteristics Of The Private Health Sector

Problem with Data Availability Qualified/Registered and Unqualified Practitioners Multiple Systems and Cross-practice Rural – Urban Divide Poor Registration and Standards of Private Hospitals Focus on curative care Unregulated Practice No price regulation Demand increases with increased supply Price escalates with increased supply System of kickbacks/cut practice Professional bodies unconcerned

Why Regulate? Regulation aims at improving clinical

performance (safety and quality) Regulation targets risk mitigation Regulation promotes ethics and social

justice Regulation to protect professional

standards

What is Regulation?

Source: Braithwaite, J., Healy, J., Dwan, K.,(2005) The Governance of Health Safety and Quality, Commonwealth of Australia

Voluntarism- is based on an individual or organisational undertaking to do the right thing without coercion.

Self-regulation- is where an organised group regulates the behaviour of its members (e.g. by establishing an industry-level code of practice).

Economic instruments- involve supply-side funding sanctions or incentives for health care providers, and also demand-side measures that give more power to consumers.

Meta-regulation- involves an external regulatory body ensuring that health care providers implement safety and quality programs and practices.

Command and control- involves enforcement by government (e.g. ensuring compliance with rules for licensing facilities).

Who should Regulate? Profession Independent agency Government Legislation Ethical codes Insurance Market

What to Regulate? Clinical practice Quality and standards Protocols Economics Ethics Legal dimensions

Regulating the Health Sector

MACRO ASPECTS

Fiscal Measures

Legal Measures

Professional Measures

MICRO ASPECTS

Audit of Medical Practice

Setting of Minimum Standards

Social Audit

Micro Aspects

Audit of Medical Practice Prescription and

Diagnostics Audit Patient Records Filing Data

Returns Bills and Receipts

Minimum Standards Quality Norms Qualification Minimum

Equipment Standard Charges Accreditation

Social Audit Consumer

activisim Local body

control Accountability

and responsibility

Global Experience From professional ethics to legislation The insurance route Examples

UK – Healthcare Commission USA – National Quality Forum Canada – Patient Safety Institute Australia – National Council for Safety and

Quality in Healthcare

Indian Experience Unorganised healthcare system Supply induced demand Poor ethics Segmented legislation – fire fighting

approach Poor accountability, even with existing

legislation Dilemma of profession versus business

Existing Regulation Medical Council of India and State

Councils Local bodies Food and Drug Administration (FDA) Clinical Establishments Act (CEA) National Accreditation Board for

Hospitals and HCPs (NABH) Indian Public Health Standards (IPHS)

Legislation Only 8 states have any legislation to regulate private

health sector MP – legislation for regulating nursing homes

introduced as early as 1973, rules framed only in 1992

Bombay Nursing Home Regulation Act – passed in 1949, not implemented

PIL in 90s by the medicofriend circle and others - in 2006, extended to all of Maharashtra

Clinical Establishments Act 2010 – strong opposition in several states

Even in states that have acts and where rules are implemented, no action against providers who didn’t register

Evidence from the field A survey of 261 private hospitals (less than 30 beds) in 11

districts of Maharashtra found that: Most hospitals did not fulfill the minimum requirements

under BNHRA 56 per cent of the hospitals under study did not have a

single qualified nurse, more than 50 per cent hospitals did not have a resident

doctor (24/7) only 14 of 114 maternity homes had a midwife. While the registration under the BNHRA was high (89

per cent), basic minimum requirements under the law such as display of certification, presence of qualified doctor and nurse, maintenance of case records were not complied with by most hospitals.

Source: CEHAT, 2010

Patient Welfare issues in Pvt Health care

Irrational use of drugs, over prescription, unnecessary diagnostics Rural, tribal, poorest most exposed to over use of

injections No standard treatment protocols Nexus between doctors and the drug industry ‘Cut Practice’ No Grievance Redressal Mechanisms Lack of information provided by health care

providers

Public Private Partnerships

Source: National Conference Report. Emerging health care models: engaging the private sector. Mumbai, 25–26 September 2009. At: <www.cehat.org/go/ uploads/PPP/reportfinal.pdf>.

There are several problems with the PPPs in health formed by the government with the private sector. The contracts between the public and private sectors have been found to be skewed in favour of the private sector. There is also hardly any evidence indicating whether or how these partnerships are increasing access to services, affecting out-of-pocket payments by patients, reducing or increasing equity or improving quality of care.

Problems with PPPs No evidence that either quality of care or

access increases with PPPs, nor that out-of-pocket payments reduce

Only take ‘safe’ cases – shifting problem – defeats the purpose

Low motivation of implementers – Maharashtra experience – reluctant to get enrolled to provide EmOC

Unnecessary procedures – often harmful – Arogyashri – hysterectomy cases among 25-40 yr old women increased by 20% since its introduction!

Problems with PPPs Problems in Contracts

No clear deliverables No clear accountability No clear planning for management No requisite standards for private partner No clauses for exit or penalty No STPs No grievance redressal mechanism No transparency in MoUs

The Case of Charitable Hospitals The charitable trust hospitals like Jaslok, Breach

Candy, Bombay Hospital, Liavati, Hinduja, Nanavati, and Kokilaben Hospitals registered under the Public Trust Act receive tax waiver benefits and several other benefits like concessional land or a cheap lease rent, extra floor space index (FSI), concessional electricity, water or property tax, waivers or concessions for other taxes like octroi, customs duty, etc. They have an obligation to provide 10% of their beds for the indigent and an additional 10% beds for economically weaker sections, which they are not fulfilling. A CEHAT study found that most of these hospitals are not complying with this at all.

Establish a National Health Regulatory and Development Authority (NHRDA)

Mandate the Accreditation of all HCPs Establish a system to independently evaluate

performance Establish a Health System portal to strengthen use

of IT Strengthen the Drugs and Medical Devices

Regulatory Authority Engage Pvt sector for provision of healthcare

through a well-defined çontracting ín mechanism.BUT – with reduced spending on public health, how

are public health facilities expected to compete?

Some recommendations of the HLEG

A comprehensive umberella Act – National Health Act

Developing a strategy for pooling financial resources deployed in health sector and redistribution based on existing resources

Allocation of health budgets as block funding, on per capita basis – redistribution of current expenditures

Contracting-in of private providers, but with proper accountability and within public health goals.

Compulsory public service by medical graduates – increase resources in public health system substantially

So where do we go from here?

Essential drugs to be brought back under price control.

Location policies Medical councils to ensure only licensed

practitioners practice Strict implementation of existing laws Strengthen health information systems

so as to facilitate better planning, audit and accountability.

References

DhawanRiya et al (2009) “Contract Management” in Emerging health care models: Engaging the private health sector” National Conference held during 25th – 26th September 2009, Mumbai. The conference report provides a very useful review of various PPP schemes. It can be accessed at http://www.cehat.org/go/uploads/PPP/reportfinal.pdf

AkashAcharya and Paul McNamee, (2009) Can Public Private Partnership reduce Maternal Mortality? Assessing efforts made by the ‘Chiranjeevi’ scheme in Gujarat , PPP Conference, CEHAT Mumbai. Moyna (2010) Menopaused 20-somethings , Down to Earth, at http://old.downtoearth.org.in/full.asp?foldername=20100615&filename=news&sid=5

Moyna (2010) Menopaused 20-somethings , Down to Earth, at http://old.downtoearth.org.in/full.asp?foldername=20100615&filename=news&sid=5 also see , http://timesofindia.indiatimes.com/india/The-uterus-snatchers-of-Andhra-/articleshow/6239344.cms

http://www.hindu.com/2010/01/26/stories/2010012653230400.htm Public-Private partnerships in India: A case for reform? Economic & political weekly, August

2009 TK Sundari Ravindran (2011) Public-private interactions in reproductive health services in

India: A mapping, CEHAT, Mumbai. Public Private Partnerships for Emergency Obstetric Care: Lessons from Maharashtra,

Indian Journal of Community medicine, Jan-March 2011 http://www.ncbi.nlm.nih.gov/pmc /articles/PMC3104703/

Patients’ Rights Charter To what extent does this charter address

the problems in the private sector? What does it not address? How would you implement this in your

setting? What challenges do you foresee?

Sana Contractor sana@cehat.org