"Poorly maintained registers of doctors". That's the first five words of the article What ails India’s approach to Universal Health Coverage in Times of India by four people from Vidhi Centre for Lobbying Legal Policy. Let's talk about that after we look at universal health coverage.
"Universal health coverage (UHC) means that all people have access to the
full range of quality health services they need, when and where they
need them, without financial hardship. It covers the full continuum of
essential health services, from health promotion to prevention,
treatment, rehabilitation, and palliative care across the life course." ~WHO
That's quite an ambitious goal, isn't it? People having access to a full range of health services where they need them, that too without putting them in poverty.
The community medicine HoD of PGIMER, Chandigrah ends an article about achieving this as:
"In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India." (emphasis mine)
Jan Swasthya Abhiyan, the Indian version of People's Health Movement, suggested in 2012 a national debate, while also saying that "providing entitlements must be accompanied by a clear framework for accountability and grievance redressal" and that "highest priority must be given to significant expansion and improvement of public health services". (emphasis, again, mine)
The Lancet lobbying group for "reimagining India's health system" in a theory of change also talks a bit about accountability.
"Finally, the fourth proposed intervention relates to creating accountability and trust in public and private health systems. Enhancing the scope of political engagement is a crucial step toward this, along with developing and disseminating performance reports on the functioning of various health systems. Communities should be able to conduct social audits of the health systems they use along principles of Community-Based Management (CBM). Establishing or strengthening the legal framework to protect and empower communities would also be essential, and a robust grievance redressal mechanism should penalize malpractice and negligence. However, care needs to be taken to ensure that caregivers are not unduly penalized."
One could indeed say that accountability and grievance redressal forms, or ought to form, a part of the path towards universal health coverage.
And that's indeed what Vidhi set out to study as per the three reports they released on Dec 5 all of which start with "Holding Healthcare Providers Accountable":
And the next paragraph in the TOI article makes it abundantly clear that they're indeed talking about these: "Healthcare providers in India are held accountable by the state through four primary mechanisms — courts, consumer fora, medical councils that regulate healthcare professionals, and regulators of clinical establishments"
This is where I begin to disagree (and this is probably where my shock comes from in reading that "poorly maintained registers of doctors" ails the approach to UHC).
When the rest of the world is talking about holding healthcare providers accountable, they're talking about the healthcare providers being held accountable by people, society, or basically healthcare consumers. For example, in the Lancet group's article above, they talk about social audits. But when Vidhi is studying this, they put on an irrelevant criteria — "by the state".
If they meant state in a larger scope wherein state includes citizens (people, society, and healthcare consumers), then they've gravely erred on the "four primary mechanisms" through which healthcare providers are held accountable in India.
When one glances through the report this becomes obvious as they have very nicely documented the numerous reasons why all of these fail to hold healthcare providers accountable. Here're some statements from their three report landing pages:
- "the apparent reluctance of courts to convict healthcare providers of medical negligence under criminal law raises questions as to the role of this mechanism as a tool of accountability in the healthcare space"
- "However, SMCs fail to perform their adjudicatory functions effectively. Very few complaints are instituted, and even when instituted, the most common disciplinary actions are warnings or mandating attendance of continuing medical education (CME), with very few instances of an RMP being removed from the register either temporarily or permanently."
- "Enforcement has continued to be unsatisfactory in various states that have adopted it. The Act also has various gaps, like the absence of grievance redressal systems, that prevent it from being an effective and patient-centric healthcare regulation. "
Yet they have persisted in their belief that these are the "primary mechanisms" of holding healthcare providers accountable.
If their argument is that they're only researching how the "state" can hold providers accountable, then there is a case to be made that "holding accountable" is not a function of the "state" — which in many cases is the "provider". The state itself has to be held accountable (at least in the case of public healthcare system). "Holding accountable" is almost always the function of consumers and citizens.
If their argument is indeed that these are the main mechanisms, and they're wrong, then what are the real primary mechanisms of holding healthcare providers accountable?
I have written about this before where I talk about avoiding legal system altogether. I write in that that we could focus on activism, politics, journalism, and research.
But what are the "primary" mechanisms?
Let's put ourselves in the shoes of a healthcare provider.
An independent private healthcare provider running a clinic. What they're the most afraid of is a patient dying and people thrashing their clinic. The mechanism of accountability here is direct physical action.
An HCP inside a private hospital. They're most worried about the person who pays them salary. And that person is most worried about the reputation of the hospital being ruined by reports of inadequate care there. The mechanism of accountability here is social messaging.
An HCP inside a public hospital. They're mostly not worried about anything. But they are indeed answerable to their medical superintendent and district level officers (like the DHO) who have the power to transfer them. And these higher officials are most worried about politicians (minister, MLA, etc). And they're the most worried about their political image being tampered by journalists writing up a series of negligent care in government hospitals.
Through this exercise in empathy what I'm trying to say is that the biggest (primary) mechanism of holding healthcare providers accountable is "social pressure".
But Vidhi is a group of lawyers. The four authors of the TOI article are lawyers. And all they can see this is as a problem of law. They can look at it only in terms of clinical establishments act, and tort law, and NMC act, and so on.
That's absolutely fine. It is very much required to have well functioning regulatory mechanisms through law.
The problem is when they claim they know more than what they know. You don't reach Universal Health Coverage by focusing on law alone. And I don't even want to go into how "poorly maintained register of doctors" has relatively little to do with holding healthcare providers accountable through law.
But all I want to say is that Vidhi should stop writing TOI articles that help Nandan Nilekani build data maximization projects like the NDHM.
