Home Features Interviews Dr. Sylvia Karpagam on Public Health and Regulation in Karnataka
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Dr. Sylvia Karpagam on Public Health and Regulation in Karnataka

Background:

Dr. Sylvia Karpagam, a public health doctor and activist talks about the different factors involved in delivery of public health(with details specific to Karnataka but which could be applied to most other states also). She talks about the failures in both public and private health care system and the need to analyse the recently proposed amendments to the Karnataka Private Medical Establishments(KPME) Act with the right perspective where healthcare is considered as a right and not as a market commodity to be sold to public.

KPME amendments are still in discussion phase and are being supported by public health groups and being opposed by private medical establishments and a section of doctors. More details on the campaign to improve the amendments to be found here – https://kpmeyake.wordpress.com/ .

The Karnataka Private Medical Establishments Act was already there since 2007, in spite of the act being there, there were lot of gaps, people who have worked around the issue of patients and patients’ rights, patients groups themselves or individuals who have had issues with the private medical establishments, felt that there is a gap. In fact the health minister, Mr. Ramesh Kumar has talked about himself having seen facing lot of issues with regard to implementation of the act and barriers to regulation. So this kind of need to bring in an amendment to KPME came in, in an organic way.

There have been a series of discussions, a committee was formed called Vikramjit Sen Committee which was intended to discuss the amendments and bring out a list of recommendations which would be introduced. Once the committee met, the government also brought out the amendment in the assembly. Once the government brought out these amendments, there were lot of protests by the private medical establishments saying that it is draconian, it is too strict, they are clamping on us and affecting our business. People’s groups or community groups said that they supported these amendments and would like few more things to be added. Doctors have been split into both the camps, some doctors are very much against these amendments and some doctors are very much in favor of these amendments. So that debate is happening, and it is a very crucial debate, in the sense it is bringing up a lot of dialogs and discussions which is very important. Doctors are articulating both sides of the arguments, some are saying why it is a problem to have regulations, some are talking about why it is important to have these regulations. The joint committee has been formed to give their own recommendations, maybe in another three or four weeks. Today, 6th July, 2017, is their first meeting, they will be giving their recommendations and hopefully these debates and discussions will influence the KPME Act amendment in some positive way.

If you look at the amendements, the private hospitals and the nursing homes association along with some representatives of IMA (Indian Medical Association) have given submission to Mr. Parmeshwar, the Home Minister of Karnataka, opposing few of the amendments. They feel that having a cap on the prices is problematic, they feel the government should not interfere in regulating the prices, and the reason they mention is that there are lot of innovative things and it curbs our ability to do research and help the patients, and it will negatively affect the patient. And people will not invest in the private sector and they have reasons to oppose it. However, some of us who come from public health background, the way we view these things is that this process of regulating the private sector has evolved over a period of time because of lot of policy failures.

If you look at health itself, if you look at the understanding of what health is, the initial WHO definition of health was “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” And for health to exist there are lot of social determinants like water, nutrition, education, sanitation, etc. If you do not have these it is very difficult to think of the idea of health. And if you look at caste, where does caste locate itself in all these things. If you look at statistics, who are the people who are more affected by health issues, who are the people who have less access to health services, who are the mothers who are dying, who are the children who are experiencing malnutrition, stunting (low height-for-age), wasting (low weight-for-height ) – it is predominantly mothers and children from the SC/ST background.

This process of regulating the private sector has evolved over a period of time because of lot of policy failures.

If you look at water, if people are not having access to water, the struggles around water; if pepsiCo is taking up whole area and using all the groundwater for their own company and people are not able to access that water. If the quality of the water is being affected by the industrial waste, if you see the water tanks and lakes, the kind of pollution that is happening, how are people expected to have health if the water is so contaminated?

Then, if you look at nutrition, the politics around nutrition, the access of people to food which is their right is more and more getting violated. Linking ICDS (Integrated Child Development Services Scheme) to Aadhaar, to go to an anganwadi or a school and to say that you do not have an Aadhaar card and so you step aside, you will not be given food – what kind of a policy is that? If you look at PDS (Public Distribution System), if you look how complicated they have made the process of accessing PDS. So, you are talking about social welfare net for people and you make it so undignified and so humiliating, you know, just to access food it becomes so difficult. And the kind of influx of processed food into market, these big companies are sitting in the policy making, they have taken over lot of these spaces, deciding what food should go as part of ICDS, they say packaged food, they are violating Supreme Court orders. The Supreme Court clearly says that corporates should not enter supply of food to children, because they see clear conflict of interests. But who cares? The government is allowing the private sector to come in, the private parties are themselves sitting in the policy making, so if food and access to food itself is becoming a problem then how do you get health? Then, how do people access health?

The same thing with sanitation, we are talking about Swachh Bharat, Swachh Bharat is not about few politicians and few film stars sweeping the streets, what is happening underground? What is happening for your sewage system? Where is your industrial waste going? Where are your apartment complexes, where are all their filth and fecal excreta and urine, where is all going? Who is cleaning it? So, unless all those things are looked at, it is very difficult to talk about health, even at a very superficial level.  

First of all, the government has failed miserably at addressing all these issues. These issues which we call social determinants of health, so instead of health being a pyramid where most of the work is at the base, that is at preventive level, and then you have primary health care which is close to the people, it meets their immediate needs, it picks up cases, for example diabetes, if you are able to talk to people about eating, the eating habits, about lifestyle, pick up diabetes early, ask them to make lifestyle changes then you are very likely to prevent the complications that come later. Same thing with kidney, they talk about kidney transplant as being very important. But, if all your investments are going into tertiary care and transplants and you are not talking about how to prevent kidney disease then your pyramid gets inverted. So most of your interventions are at the top, which is at the tertiary level, so health care become very complicated, complex driven by the tertiary care model which is not sustainable. And certainly it will not help in terms of health as a larger social good.

For health to exist there are lot of social determinants like water, nutrition, education, sanitation, etc. If you do not have these it is very difficult to think of the idea of health.

So that was the first failing of the government, that is they did not focus on the primary level of health care. They allowed a situation of gradual destruction and erosion of the primary health care and of preventive health care. And the focus became more and more based on the tertiary model. Then the government instead of addressing that gap and trying to strengthen the existing public health care systems, they went further and what they did is bring in these schemes. Now in Karnataka what we have is a Yashaswini Health Scheme, Vajpayee Arogyasri, RSBY (Rashtriya Swasthya Bima Yojana), RSBY actually never took off in Karnataka, but with all these new schemes they brought in a new parallel structure to run those schemes, they empanelled private hospitals. Of course the private hospitals started holding the government to ransom. Because, if you look at the basic principle on which the private hospital functions – it is an industry, most of them who have come, who are talking about it are saying exactly that, they say we are traders, it is a business, a market, first it is an investment, we want to see returns. And, the government has gone and handed over the health care to them, so they say this money is not enough for this procedure, they want to do procedures that they feel are more lucrative for them. So this idea of cherry picking is there, if you look at these models, where you take patients who are more beneficial to you, you leave out those patients, like patients who need long term care, patients who need lot of interventions, for example a terminal cancer patient is not as simple as doing one small surgery like hysterectomy and you make your money, patient will need care, long term care, those kind of patients are getting left out in this name of health care being lucrative. So government is not some victim here, or it is not an innocent bystander, the government as a policymaker should have anticipated this, which they have failed to do. And, now they are in a situation where the private health care industry is holding the government for a ransom. So, now, the health minister is saying, some hospitals are claiming one lakh, and some other hospitals are claiming two lakhs, it is taxpayers money, so we now have to regulate. So, the regulation can not come as an afterthought, can not come in retrospect, you have to anticipate, you have to prevent, you have to preempt, you have to see in the long run what is the best in term of health outcomes for your country or your state. In Karnataka, the government is culpable for the situation that is happening now.

A lot of doctors are anger with this idea of regulation. They questions ask like – “are we traders? Why are you treating us like this? What happened to the trust that was there between doctors and patients?” And then, if you give examples and you talk about the violations that happened, then they say “there might be few rotten apples, others maybe doing it, I do not do.” So, the question is, say even among thousand doctors nine hundred and ninety nine are ethical doctors who look out for patients’ needs and patients’ rights, and there are one or two doctors who are causing harm or death or some kind of negative outcome then the question is should they be regulated or not? And, the logic that the health itself being a market commodity is very flawed. So, if you look at a TV or a fridge, if someone wants to buy a television, they have an element of choice, they can go, they can look, they can say my budget is ten thousand or my budget is one lakh and someone might say I do not have money for this, I want to invest in my child’s education or I want to buy something else because that is more important for my house at this point or I just want to save. So, there are a lot of choice if it is a market commodity. But, if you look at health, the element of choice is removed. If someone is sick you can not make a choice. When a patient comes to the hospital, or when a family brings a patient to the hospital, they come because they absolutely have to do it, bring that person there. And to then tell them that under this scheme it costs so much, or if you are ready to invest extra money it costs so much, this one gives you 10% success, that one gives you 20% success, and then ask people to decide, there is an intrinsic problem with that. So, it is ok to give the patient a choice about the facilities, of where they want to stay and the room and those kind of things, but I do not think it is ethical to differentiate between patients based on their paying ability. Say in terms of, do you treat them if there is an emergency? Do you take them or not? Do you give them the best care? Do you give them respect? I think those things are non-negotiable.

So most of your interventions are at the top, which is at the tertiary level, so health care become very complicated, complex driven by the tertiary care model which is not sustainable.

If you look at the amendment, it says, if the patient comes in emergency, they are not like saying for every patient who comes do not ask if they cannot pay, if they are coming in life-or-death situation, road traffic accident, attempted suicide, or a medical crisis, suddenly they have collapsed, they are not breathing, if a patient comes in such a situation do you then ask them can you pay? Give an advance, go pay and come twenty thousand. None of us carry that kind of money. So the first instance of the patient coming in an emergency give care and then look at other things. Is that a principle as a medical community we want to follow? That is the question we need to ask ourselves, forget about the regulation, forget about if you are working in a government hospital or private hospital. Is that an imperative for us as medical professionals? We need to think about that.

The second thing is to have a cap. So doctors are saying, not just doctors, people who have invested in hospitals, in private medical establishments, huge corporate hospitals, for them it is about returns, in terms of profits, in terms of return of investments. So the amendment clearly says that it is a group of people from those establishments will decide an upper limit. Recently there has been this case of cardiac stents, it is not about the patients being charged for like 100% or 200% profit, they have been charged for 1000% profit by the medical establishments, sometimes 2000%. So, is that acceptable? Is that acceptable that a patient is paying out of their pocket or even say the insurance companies are paying, the costs that are massive, much more than what the product costs. If your stent costs something can you have an unlimited charge that you put on the patient? This is something we need to think about. And because of that, because we feel we do not have a regulation in place, what are the consequences of that? What are the costs in terms of our relationship with patients? What are the costs in terms of ethics? What are the costs in terms of the burdens we are putting on patient? So, if a patient can pay, does it mean we should charge? Does it mean that if a patient can pay in lakhs for a treatment therefore we should charge in lakhs? Is that how we should operate?

If you look at the case of dengue, dengue most of the time can be managed at home and the government has quite good guidelines, cause the agenda is to handle the dengue case and to control it’s negative outcomes. Of course, the government would have done better if they would have worked on preventing dengue, because every year dengue is happening, every year mosquitoes are breeding and every year we do nothing. We just do a stop gap thing, once the cases come then everyone is active doing something, it is not that the government can not take more measures to prevent dengue. But, if you look at what is happening in the private sector, and these are documented cases, there is research, there are anecdotal cases, it is not like people are simply sitting and talking loosely, dengue is very lucrative, so if a patient comes to the hospital, you will not say that go home, take a crocin, take rest, treat the fever, monitor your platelet counts, if you get these symptoms of hemorrhagic fever then come back immediately, you need admission, you need platelets, so most cases of dengue would not be in the hospitals. But as soon as the patient comes, you make a big thing, patient has dengue, everybody gets frightened, there is whole fear around dengue and people are capitalising on it. They are capitalising on the fear people are having about a disease that you know, you have heard cases about people dying due to dengue. The doctor or the establishment has the moral imperative to say that all cases of dengue do not die. However, on the contrary if you say, admit the patient, immediately put them in ICU, and platelets and everything, and patients are getting a bill somewhere between seventy thousand to a lakh for something that could have been managed at home. Of course, there are cases of dengue haemorrhagic fever which can lead to death, which can be fatal, which need care, so if your system is there to treat those and only those kind of cases which really need the care then it is a fair system. It is an ethical system. But if you are capitalising on the fear of that consequence that happens to a few people and therefore the rest of them become your captive group then there is an ethical concern there.

The logic that the health itself being a market commodity is very flawed.

The third thing is about when a patient dies in a hospital, what happens then? Do you keep the body there refusing to give the body saying settle your bills? Recently there was a case of a young man who came from Bidar, who must have been in his 20s or 30s, and he had quite a fatal illness, so when we asked other neurologists and neurosurgeons they said he needs palliative care, there can be nothing done, talk to his family, counsell them. it is very important for a patient to know if the disease is curable or not, if it is worthwhile investing that much money and we are not making the judgement,  we are not saying you have to do it or you do not have to do it. “oh! He is going to die, go home”, we do not say that but what you say is that the chances of survival is very low and the cost of treatment is so much, you choose, that is what we call as informed consent. Where in you give all the information, both the positive and the negative to the patient and their family, and ask them to choose. Sometimes you need to help them make the decision cause the doctors are the experts, the doctors can not say “you go decide, choose and come back and tell us”. It is not that simple as that. It is process of negotiating with the patient the absolutely central to the whole process.

This patient who came with terminal illness was never told that it was so bad, immediately he was asked to a surgery, the surgery did not help, by then his bill was three or four lakhs, and then they said you have to another surgery. The patient’s family said they would like to get a second opinion, but the doctors said “No, you have to first settle this bill and then you can go for second opinion”. The patient’s family could not  settle the bill and so they had to stay in the hospital, they were literally held on ransom, the patient was not allowed to go out. Finally, the Human Rights Commission had to intervene, by then the patient had died and the bill was around 12 lakhs. So the question is, should this patient have been told? Should this patient have been given a choice? Should the patient have been allowed to have a second opinion? And once the patient has died, should you hold the body and refuse to give the body because his bills have not been settled? So, how much of it is your market ethics logic? How much of it is your medical ethics? These are all the discussion that should be had. Nobody says that the government is good, private is bad, these good and bad arguments are very polemic and they make no sense at the end of the day. But, what is best for the patient? Is the patient a commodity that you fight for? Is the patient a consumer with a lot of choice, who you therefore can give complete decision making to? What about rights? What about patients who sell land, take loans and come to pay for this health care, do you call them as patients who can afford to pay? So, the question of affordability of health care is problematic. A lot of private establishments say “ If patients want to pay what is your problem?”. So “want to pay” as opposed to “have to pay”, let us say my child is in a hospital, or someone who is very important to me, and the doctors are saying that “this procedure has to be done and this is how much it will cost”, do I say “No, I want to pay”  is that given a choice is that something I will invest my money in? Or is the question of choice completely removed? So, what are we negotiating here? Like, where does ethics come into this dimension?

If you look at this idea of grievance redressal, again the argument against a separate body or independent body for grievance redressal is that there are already consumer court and KMC which is Karnataka Medical Council, so why have another independent body? If look at the existing grievance redressal mechanism there is a huge gap. First of all, there is knowledge gap We have been part of some of these KMC appeals. There is this case of a person whose wife died in one of these big hospitals. He lost his wife and child, and there was evidence of negligence; the doctor had not come to see her; she had complains the whole night; repeatedly call were made to doctor; prescriptions were given over the phone; the dosage of medication was wrong; the medication that was supposed to be given on empty stomach was given after giving food. So things had happened and the family felt that they had not received proper care. The family maybe wrong, maybe they received the best care, but if they feel the care was not given, there is a body they would like to approach, just for their own sense of satisfaction; yes, we have taken our loved one to the hospital and the expert committee also said that the best possible care was given; there is a sense of closure that we have done our best.

Once the patient has died, should you hold the body and refuse to give the body because his bills have not been settled? So, how much of it is your market ethics logic? How much of it is your medical ethics?

So this person has started a campaign, JusticeForAparna, that is he still feels that his wife who is no more has not received justice. They had approached KMC, and it was so much a case of mismatch of power, so you have a group of expert doctors, they are sitting there in their whole corporate attitude, the ones with the knowledge, the family is there, his father was literally in tears because of what has happened. First of all there is lack of sensitivity, beyond looking this right and wrong looking at this person who has lost someone to empathise, to share that I understand your pain is totally lacking. There is this top-down attitude of – you do not know – “Nimage gottilla, namage gottu”. And it is very difficult to find an expert doctor who will say “yes, what my colleague did was wrong”, it is very difficult. We have heard people saying “yes, it was wrong but do not put it on record. yes, I would not have done it. It was negligence. The doctor should have done something else”. But when you ask them, “would you come and testify? Would you say that in public?”, they will say no. The same thing happens at KMC, where doctors say “ the doctor may have had a valid reason to do it. The doctor and the establishment might have done it in goodwill”. So the benefit of doubt is always going to the management, the establishment, to the doctors, it is very rare for instances where the patients feeling that “we were heard in objective manner” even if the outcome is that the doctor was right. So, I do not think that the patient groups go to KMC or consumer court with vindictive interests. Of course, there maybe people who it cause for every rule there is an exception, but when they go there is a sense of loss, there is sense of something having gone wrong which they may not be able to completely understand and articulate. But there is an objective body that they can go to, which looks at it neutrally, which is not taking sides, which is not abusing power, and even if they tell a patient “no, we have looked at the case and we feel that the doctors have done it in your best interest” that gives a sense of closure. So, it is important to have that body for people to go to. The consumer court, as we said earlier, it (health care) is not a commodity, it is not like my product was bad and therefore I am going to the consumer court, it is not an adequate body. Definitely that body can itself be biased, can also have problems, can also be tampered with, it can be influenced, so we try to bring in checks and balances to regulate it.

But, I think it (the amendment ) is most importantly for doctors, the medical profession to revisit what is happening. Because, lot of junior doctors, a lot of doctors who come in with certain ethics, they do feel a sense of the ethics having to be compromised. There is currently a survey that is running of medical doctors who are writing, it is confidential and anonymous, to share what they feel they are forced to do, so if a doctor is not able to prescribe a drug because the medical establishment is saying “you should prescribe something else that is little more costly”, where do you draw the line? If they say “Why are you not doing enough procedures? Why are you not generating enough income for the hospital?”. If I as a doctor am sitting in a private establishment and I am generating no revenue for the establishment, for example, I get ten cases of dengue and I tell to all of them “No, you do not need to be admitted, go home.” I am less valuable than a doctor who frightens the patients and says “You need ICU admission”, who generates a bill from every patient, generates revenue for the hospital. So this amendment also protects those ethical doctors who feel that an establishment can not control the treatment, the finances and the market logic can not control treatment for a patient. Even for those doctors these amendments are protective. It is important for doctors to discuss it, even if they oppose it to come up with real reasons as to why they are opposing it. To examine how these amendments actually help the larger picture. And, to look at it from the patient’s’ point of view, to locate the patient as very central and to visualize it – (a) as a patient and (b) as a profession that was there for the patient in the first place. It was never a profession for profits. Of course the profits are important, it is important that people get salaries and incomes and they are able to have a reasonable life and lifestyle. But that can not become the only factor to determine your choice about whether this amendment should come in or not. Hence, the perspective of looking at these amendments is very important, then the negotiating with the government would help.

Dr. Sylvia Karpagam, is a public health doctor, researcher and an activist. She studies Public Policy Analysis, Public health systems and services research, and Relevance of caste in contemporary indian society. She writes actively on her blog and her publications and articles are available online for download.

Video: Rakesh Ram S, Transcription: Archana Bidargaddi