“DAK president Dr Nisar ul Hassan reinstated”, read the headline of a news item (GK/14-08-2018). What was reported further in detail was this: “four years after he was placed under suspension for raising voice against fake drug perpetrators”. There is an unusual tinge of Arendtian banality in this sentence. It ends with the same ruthlessness as it begins with. “Why?”, “Who?” and “How?” remain unasked and unanswered. The silence is deafening, reminding one of what the German political scientist Elizabeth Noelle Neumann calls “the spiral of silence”. Today we make noises only when something good happens, not when something bad happens. Corruption is normal and honesty is abnormal. So is the case with violence and non-violence. So welcome to the era of inversion of conventions!
The inversion of conventions has had an impact on almost all sectors affecting human life and predominantly on the healthcare system. Dr Nisar’s incident should have served as a “tornado alarm”, a peek into the disruption going on in the field of medicine, but alas our penchant for banality. A kind of bucolic innocence makes us ignore the problem with the hope that it will go away of its own. Our fascination for the morality play has blinded us towards the systematic conceptualisation of the problem in solid legal-political, social and economic context. We are not able to catch-up with the flow and much of this has to do with the reality of burgeoning neo-liberal structures wherein regulation is limping far behind the so called unbridled freedom. Thus it is not a mere coincidence that the growth of medical legal jurisprudence has not kept pace (and is out of sync) with the phenomenal rise of private healthcare systems.
There is utter confusion over the exact role of “public” and “private” in these sectors e.g. there are almost 200 members of Parliament today in India whose primary source of income is education raising the question of serious conflict of interest (the fate of healthcare is same). Thus there is no clarity on what form of regulation should be there in these sectors. This is possibly the reason that healthcare sector specifically faces the coercion of both bureaucracy (State) as well as commercialization (Capital) resulting into what has been aptly described as “under-regulatory and over-regulatory malfunction”. Borrowing from Durkheim’s sociological observation we can say that when it comes to regulation in the world of medicine “old gods are growing old or are already dead and new ones are not yet born”.
In the godless world of medicine beleaguered consumers have been transformed into cash cows. There is effective colluding and lobbying among different stakeholders and a critical illness is a goldmine in this world. The saga of holiday trips and fancy gifts to doctors as a precursor to unethical and unfair drug selling practices is hardly lost on anyone. When it comes to India’s pharmaceutical sector there is no true competition in it. On the other hand there is a deliberate attempt to keep the capacity of healthcare system (especially public) stunted, resulting in a serious demand-supply gap (disease burden is increasing at geometrical rate while medical service at arithmetic rate). Also here we cannot miss the mention of medical education in India. We have a Western Model of medical education and regulatory structure at place in the backdrop of “third-world infrastructure with Indian needs”. This is what has made medical education a highly elitist affair in this part of the world. It takes around 400 crores to establish a medical college in India while e.g. in US a rented 50,000 square feet does the job. No wonder we see a perverse structure of meritocracy assigned to medical profession.
Furthermore, in a country like India where the socio-economic profile of people is much lower than world average public healthcare system should have been given a central stage. But what we have seen instead is a privatization spree coupled with the failure in drafting of a comprehensive policy framework and implementation of stated objectives. Over the last few years the budget on public healthcare has been slashed by more than 20 percent. The primary healthcare budget is dismal 1500 crore. According to a report of Ministry of Health and Family Welfare there is a 22 percent shortfall in Primary Health Centres while 80 percent of posts in Community Healthcare Centres in rural India are vacant. Out of about one million doctors only 10 percent work in public sector. There is one doctor for every 10,000 people, one hospital bed for every 2000 people and one government hospital for every one lakh people in India. A recent report by Comptroller and Auditor General of India states that there is a 27 percentage shortage in clinical equipments and 56 percent shortage in non-clinical equipments in government hospitals. On face of it the National Sample Survey data reveals that the share of private medical services is 60 percent and 70 percent for rural and urban India respectively.
In a situation where people on an average incur 80 percent out of the pocket cost on medical facilities health crisis is often a precursor to financial crisis. Imagine what monopoly could mean in a country where there are just 2000 cardiac surgeons for 1.2 billion people, where, as per WHO, there are about 57 percent unqualified medical practitioners with just 1 in 5 doctors in rural India qualified to practice medicine, where pharmaceutical companies are having a field day at the expense of the well being of millions of people. Please imagine. Passing on buck to private sector not only has had a bad global experience but it also shows how a state is skeptical towards its own capacity. Private sector can play a complementary role, not a supplementary role. We can of course have a free market, but “market in its place”. When even the free markets of West can have a price controlling mechanism, why can’t we have something like the “Dharma of Medicine” in India?
Coming back to Dr Nisar’s incident and ongoing busting of unregistered and fake medical practitioners in different parts of Kashmir, one thing becomes clear: business as usual cannot be a business anymore. It’s time people started talking about it as in the words of Amartya Sen, “the bane of public healthcare in India owes much to the silence of its people”. A collaborative mechanism with all stakeholders on board, seriousness on part of people at helm, a small effort by upright doctors, a little bit of soul-searching and our voices in chorus can make a huge difference. This is the only way we can achieve the troika of quality, affordability and access in our healthcare system.
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