By Shweta Marathe and Abhay Shukla of the Private Sector in Health TWG
This blog post is based on the article entitled ‘Making Private Health Care Accountable: Mobilising Civil Society and Ethical Doctors in India’ in the IDS Bulletin, published in May 2018. This new edition of the IDS Bulletin focuses on ‘Accountability for Health Equity’, which places relationships of power at the centre of our understanding of how health systems function – or don’t – for all levels of society.
A seven-year-old girl with dengue died after treatment in a corporate hospital near Delhi. A bill of 1.6 million rupees was presented to the family for 15 days of treatment, including charges for 2,700 pairs of gloves and 600 syringes.
Thousands of such cases of medical malpractice are surfacing in the increasingly commercialized private healthcare sector in India. Sadly, several cases cannot even stand in court due to the lack of sufficient evidence. Although private providers dominate healthcare provisioning in India, so far, this sector has been almost completely unaccountable to its users. Furthermore, it is very weakly regulated when it comes to quality of care, rates for procedures, or standard guidelines for medical treatment. Mechanisms for grievance redressal for ordinary patients are practically non-existent. Fifty-three percent of complaints registered with Maharashtra Medical Council since 1995 are awaiting justice.
In this context, diverse and innovative approaches, which have evolved over the last decade, are now being employed by civil society networks in the state of Maharashtra, in India, to ensure social accountability of the private healthcare sector. These efforts could provide valuable lessons for similar processes concerning social accountability of private healthcare providers in LMICs across the globe.
Working with civil society, ethical doctors and the State
Ongoing initiatives have involved a three-pronged strategy of mobilizing civil society organizations, networking among sections of doctors interested in ethical practice, and advocating with the state for regulation of the private healthcare sector. Three key actors- the health rights civil society organisation SATHI; the People’s Health Movement (PHM) in Maharashtra state; and the Alliance of Doctors for Ethical Healthcare (ADEH) – have played significant roles in these processes.
1. Mobilizing civil society organizations and citizens for patients’ rights
The main discourse for the mobilization of citizens to highlight malpractices in the private healthcare sector has been the demand for protection of patients’ rights, through various channels.
- A major public hearing was organised by PHM and the National Human Rights Commission (NHRC) of India, in January 2016, to present human rights violations in public and private healthcare facilities. Though the NHRC did not hear cases related to private hospitals citing its lack of legal jurisdiction over them, it recommended that the state should enact regulatory legislation, as well as amend the Medical Council Act to ensure regulation of private hospitals with protection of patients’ rights.
- ‘Citizen–Doctor Forums’ (CDF) have been formed in two metropolitan cities: Mumbai and Pune. Recognizing the need to move beyond adversarial ‘patients vs doctors’ type positions, CDFs bring together active citizens, especially those who have suffered violations in private hospitals, alongside doctors who are supportive of rational, ethical medical care. These forums provide technical and social support to patients, while generating awareness on patients’ rights.
- PHM launched the ‘People’s poll’ on patients’ rights campaign in Pune district, in mid-2017. In this innovative activity, over 21,000 people cast their ‘vote’ on a ‘ballot paper’, in which they were asked their opinion regarding the protection of patients’ rights, the regulation of private hospitals, and the improved quality of care from public hospitals. Ninety-nine per cent of voters expressed their support for all three measures. The campaign was well received by media, and the results were shared with Legislative Assembly members, the Health minister and Chief Minister of the state.
2. Advocacy with the state for regulatory legislation.
PHM Maharashtra led the formulation of a Charter of Patients’ Rights and Responsibilities, through dialogue with the Indian Medical Association in 2010. This was followed by mass demonstrations during the Legislative Assembly sessions demanding a state-specific, comprehensive Clinical Establishments Act. This in turn led to the formation of a multi-stakeholder committee to draft such an act. The draft act includes key provisions like Charter of Patients’ Rights, rate transparency, multi-stakeholder appellate bodies and grievance redressal mechanisms.
3. Networking among doctors to promote ethical health care
ADEH was formed in 2016 as a pan-Indian network of doctors promoting ethical and rational health care and seeking alternatives to the commercialisation of healthcare. ADEH has made noteworthy interventions including: the public demand for reform of the Medical Council of India; providing technical inputs to the National Pharmaceutical Pricing Authority towards fixing prices of healthcare devices; and submitting suggestions regarding the draft ‘National Medical Commission’.
Re-imagining regulation with the lens of social accountability
These participatory actions have contributed to creating a discourse around patients’ rights and regulation of private healthcare sector, involving citizens as well as doctors. Such experiences can inform the emerging concept of ‘social regulation’ wherein regulatory bodies are held accountable to a wider range of citizens and stakeholders. It is now crucial to take forward such processes across the country, generating political will for effective and accountable regulation of the private healthcare sector. This is essential for ensuring the rights of all users of healthcare, a cause that concerns all of us as potential patients or carers.