Don't Jump On Private Healthcare

People from Koodam asked for opinion on the PIL in Supreme Court regarding fees in private hospitals (and clinical establishments act). They shared a folder collating views of various individuals, including this excellent working paper which I refer to in the text below as Oxfam publication.

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 Hi Gayatri, I went through the whole folder. All I wanted to know was what Koodam was. But, lol. Anyhow. What I'm going to write is obviously my personal understanding of the transformative nature of law (and the limits of it). It is going to be biased by my worldview. I'm going to label them explicitly as much as possible.

Regarding the nature of documents in the folder. The compilation, over all, is very nice. That's mostly because of the excellent documents prepared by JSA. Minus that, the arguments and the scholarship is rather weak. Koodam which explicitly says "diverse views" has the least diverse of views. The Oxfam publication by Abhay Shukla, et al is perhaps all that one needs to read.

Regarding non-additive nature of law, and the paradox of how parts are worse than the whole. I am not sure how well I can articulate this. But basically, for law to act in transformative way, a series of measures that are all reinforcing each other need to be enacted together. This is hinted to in the JSA/Oxfam publication. If there's unbalanced law that's enacted, it creates all kinds of unpredictable troubles. In law, 1 + 1 + 1 is not the same as 3. The order of laws, the simultaneousness of it, everything matters.

If there's unbalanced push for price regulation, without other mechanisms that lead to a holistic transformative change (eg: competition introduced by well functioning public healthcare, financial support from government, in-sourcing of private healthcare providers, control on corruption, etc), then there'll be more failures than success. Examples of this generated by AI: https://www.perplexity.ai/search/Give-me-examples-k9aCXE9ERCyq9LnFzWDvZA

Private sector is not a homogenous villain: Various documents here takes a black-and-white opposition to "private". This is wrong in two ways - politically and conceptually.

Politically, if one were to really get this going against the "medical industrial complex" and IMA and so on, one has to cleave the opposition (divide and rule). And the easiest (?) way to do that is to turn small clinics against big hospitals. Putting all private providers in one bucket only helps solidifying them as one bloc

Conceptually, all the accusations against medical industrial complex applies only to big hospitals. But the "dominant" private healthcare system is not big hospitals, it is the clinics and the single practitioners. If the argument is that these are all corrupt, it is an unwinnable argument. Firstly, a lot of these clinics and single practitioners are not corrupt. They're just people like you and me going about their daily lives, with as much influence of capitalism as every other profession has. Secondly, one just can't call an entire class of profession corrupt unless one is also going to radically restructure the world and actually thinking of revolution.

On the specifics of fixing price: Fixing price is a thoroughly impractical, de-contextualized solution. Chinu's very brief response is very important. Fixing price might actually cause increase in price. I have written about consultation fees in general practice https://mbbshacker.blogspot.com/2019/09/the-curious-case-of-consultation-fees.html - the biggest challenge for me as a practitioner is that I've to make it sustainable while at the same time charging a bit fairly. Fixed price almost never works for me. If I'm forced to, I'll choose a higher price. And there's nothing in the CEA that prevents me from choosing a higher price. So, in turn, there's not much that transparency achieves (is this the point that Amar  is making? I read it too fast)

On market: My father had a sagittal sinus thrombosis a few years back. I am thankful that there was an Aster MIMS in Kannur. I didn't care about the money at all. There's an upper class in India (like my family) that prefers to not worry about cost, but only worry about health. This market exists.
I hate capitalism. But one thing I know about the world is that when there is a market for something, there's no regulation which can stop that from being capitalized. By hook, or by crook, things will happen. This is true for banning alcohol, weed, drugs, and so on. This is true for organ trade, human trafficking, and so on. This is true for almost everything. We really can't fight the market.

On the political climate: There's a section on political economy in the Oxfam publication. But what about the political climate? What political will is there in the present political scenarios to look at deep societal transformation in the areas of health. This is a high risk gamble with low rewards for politicians.

Am I being too pessimistic?: No, I'm really surprised why the Koodam didn't take up the issue of "right to healthcare" which is much easier to understand, has a momentum going for it, and can be used to focus both on public healthcare and private healthcare. Taking CEA from a decade ago seems ill-timed. Unless of course, this is placed in the larger context of right to healthcare and the focus is shifted to the patient rights charter. We really need to build an alliance with small private clinics and practitioners. Something like patient rights charter is such an easy first step

What is mfc?

A year ago, I asked in mfc's own e-group this question. You can read that long email and another long email after a week with more ideas of what mfc is here. It ends with an appreciation of what the website presently says about mfc:

It is an organization which has operated for forty eight years as a ’thought current’ without allegiance to a specific ideology. Its only commitment has been to intervene in and understand the debates, policies and practices of health in Independent India. The understanding that our present health service is lopsided and is in the interest of a privileged few prevails as a common conviction.  It has critically been analyzing the existing health care system and has tried to evolve an appropriate approach towards health care which is humane, and which can meet the needs of the vast majority of the people in our country.

[If anyone knows who wrote this, please let me know]

Of course, this has to be updated to say "50 years" now because mfc just had its 50th annual meet at Sewagram last week.

In the 49th annual meet during the general body meeting there was a comment by someone that they didn't want people who ask things like "what is mfc" [in a mocking tone] in their volunteer group for 50th year meet. Funnily enough, the 50th meet and the bulletin released was revolving around exactly this question on identity.

Ritu Priya's article was titled "The Debt I Owe to MFC as the ‘Informal University’"

Anant Phadke's article was titled "My Reflections on MFC A Consistent Yet Feeble Pro-People Platform in Health care; The Fee-less, Open University of Community Health"

Sathyamala quoted from their own previous editorial

MFC is an organization. No, it is a circle of friends. No, it is a thought current. No, it is not even an effective thought current. MFC should debate issues. No, mfc should act. No, mfc is only for Mitra Milan. No, mfc should take stands. MFC has missed the bus. MFC members are unfriendly. MFC is like a family. The Bulletin serves no purpose. Bulletin must continue. Close the Bulletin. The Bulletin is MFC’s life line. Let us decide once and for all what is mfc. How can we decide once and for all what is mfc? MFC is not professional enough. MFC is too elitist. MFC which way to go, which way not to go. (Sathyamala 1998)

Sathya then goes on to call mfc as an "epistemic community".

The rest of the articles are also about what expectations from mfc have been and what mfc have been able to or not able to do.

Similarly, in the meet, there was a session about mfc and its future. There was the idea of forming a steering group to define a constitution for mfc and decide on questions like maintenance of website, bulletin, etc. The Q&A session here also spent considerable time in the question of what mfc is. This took the form of a debate between mfc defined as a "friend circle" and mfc as defined in the brochure:

The Medico Friend Circle (mfc) is a nation-wide platform of secular, pluralist, and pro–people, pro-poor health practitioners, scientists and social activists interested in the health problems of the people of India. Since its inception in 1974, mfc has critically analyzed the existing health care system and has tried to evolve an appropriate approach towards health care which is humane and which can meet the needs of the vast majority of the people in our country.

In this post, I'll look at this issue once again and try to define what mfc is, or at least what mfc is not (as Ashok Bhargava once suggested).

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Before we go into that, we need to discuss a couple of things about defining mfc.

Firstly, defining what mfc is and defining what mfc should be are two different things. What mfc is is a (difficult) question of describing the reality of mfc as close to possible which can be done by anyone who has spent sufficient time observing mfc. What mfc should be is an even more difficult question which requires consensus and vision, and brings up plenty of other operational issues. In this post I'll focus first on defining mfc, and at the end venture slightly into what mfc should be.

Secondly, what mfc is and what mfc did are two closely related yet separate questions. Plenty of times people equate these questions and end up in a soup. The answer to what mfc did is indeed useful in understanding what mfc is. But if we just rely on what mfc did to define what mfc is, we will land up in improbable expectations from it.

And finally, defining mfc is an attempt to seriously engage with mfc and should not be seen as an attempt to diss mfc.

So, let us first look at what mfc is not:

...an organisation coming together for collective action at times of a crisis

Yes, mfc did it. During Bhopal disaster, mfc came together for collective action. During carnage in Gujarat in 2022, mfc came together for collective action. For access to drugs, AIDAN was formed collectively. But these are things that mfc did. There's no guarantee that mfc will come together at times of a crisis. Manipur and Gaza were made discussion topics at mfc annual meet in Feb 2024 probably in an effort to resume this collective action. But that's not what mfc is. mfc is not an organization meant for action. It doesn't have a budget. It doesn't have any paid staff. It is not meant for any action.

...an epistemic community influencing health policy

Yes, many people from mfc did participate in the run up to National Rural Health Mission. Yes, people from mfc have done judiciary activism. Yes, mfc has a big role in JSA. But mfc cannot be an epistemic community because an epistemic community is a network of recognized experts. mfc has always been open to anyone - expert or not. Of course, mfc does include experts who could form an epistemic community of their own. But mfc also includes non-experts. And therefore, by definition it cannot be an epistemic community. 

...a friend circle

This is probably the hardest to convince people in mfc that mfc is not. Even people who don't want to define mfc primarily as a friend circle will say that it is indeed a friend circle, at least secondarily. I believe that this definition of mfc is also in the realm of what mfc did and also what mfc should be, rather than what mfc is. To define mfc as a friend circle, though, would be stretching the definition of friend circle. Sure, I have made and nurture several deep friendships through mfc. But mfc is primarily composed of strangers. In the e-group, as of today, there are 716 members. I barely know 50 of them. Most people in mfc don't know most people in mfc. There are also people I find annoying within mfc. People I would never call friends. It is very difficult to call mfc a friend circle, no matter how warm the environment is and how friendly people are.

...a think tank

Think tank is defined as a "group of experts brought together, usually by a government, to develop ideas on a particular subject and to make suggestions for action". mfc disqualifies for reasons mentioned above under epistemic community.

 ...a thought current

If you read the emails linked above, you'll see that the word thought-current itself is a buzzword that leaves us no further than what we began with. If you define thought-current as think-tank above, then mfc doesn't qualify. Basically, it is a circular definition.

...a platform for exchange of ideas related to people’s health

This probably would have been a nice definition for mfc in 1970s and 80s assuming there was no other platform for exchange of ideas related to people's health. But in 2024 when you have plenty of avenues for publishing ideas and exchanging it with the rest of the world and instantly getting feedback thus furthering the exchange, to call mfc a platform would be demeaning the word "platform". Of note is also the fact that mfc had a barely functioning website till last year. mfc continues to not have a social media presence. It is very difficult to convince someone interested in people's health in 2024 to join mfc for exchange of ideas.

What is mfc?

Let me reiterate what I said above. By discarding these "definitions" I'm not trying to say that mfc has not served these roles or that mfc should not be these things. I'm simply trying to say that mfc needs to be defined more accurately to represent the reality.

At this point, it would be a disappointment if I didn't present an alternate definition.

Let me first document a couple of definitions that I discarded.

I had tried to draw an analogy to an alumni association. An alumni association is just a group that exists because of some historical coincidence. It doesn't have particular objectives or structure. It is just a group that exists, have shared nostalgia, etc. This doesn't accurately describe mfc either.

Then I thought about saying "mfc is a hashtag". mfc is like a hashtag people use on twitter where there is not much of a structure, but things could happen sporadically. And there is a lot of discussion around the same hashtag. But then I found something better (thanks to AI)

mfc is a community of interest

Wikipedia says the following:

A community of interest, or interest-based community, is a community of people who share a common interest or passion. These people exchange ideas and thoughts about the given passion, but may know (or care) little about each other outside this area. Participation in a community of interest can be compelling, entertaining and create a community where people return frequently and remain for extended periods. Frequently, they cannot be easily defined by a particular geographical area. 

The difference from epistemic communities and "community of practice" is that in community of interest, expertise is not a pre-requisite. Anyone can join a community of interest.

Let's not forget what a "community" is: "A community is a social unit (a group of living things) with a shared socially significant characteristic, such as place, set of norms, culture, religion, values, customs, or identity."

mfc is a community of interest that's formed around the shared interest of a pro-people, pro-poor health system. Experts and non-experts are welcome to participate. The main mode of exchange of ideas in mfc have been through yearly meeting, publishing a bulletin, and discussing on an e-group, all organized democratically and with a spirit of friendship that transcends ideological divides.

mfc going forward

I would have to be the kind of academic I hate to describe something to great detail and do nothing with that.

Going forward, there are a few things I would like to do with/through the mfc community (that should be the name!):

1. Tap into the knowledge that is embedded within individuals in the mfc community and make this tacit knowledge more explicit through discussions that are centered around such knowledge — for example, knowledge on how to solve some of the problems encountered while traveling towards Health-for-all.
2. Surface individuals and groups that are setting good examples into the public consciousness through corrective and creative use of powerful tools like the internet.
   
3. Develop the strengths of mfc as a healing community for saving disillusioned medicos from anti-people healthcare system and manifest in them the vision of a pro-people health system and the skillset required to reach there.
4. Embrace the concept of an open/informal university and bring together all groups/individuals with similar thought-processes (SOCHARA, CMC Vellore, THI/travel fellowship, etc) to double down on the concept of open/informal university and internet based pedagogies.
5. Nurture the/a community of practice within mfc that serves as a reliable knowledge respository for communities of action like JSA and SAA-K.
6. ...
7. ...
8. ... 
9. ...
10. ...
    

References

• https://www.perplexity.ai/search/What-do-you-fap4YqMJRnStnJtgFGSB9g
• https://en.wikipedia.org/wiki/Virtual_community_of_practice
• https://en.wikipedia.org/wiki/Community_of_interest
• https://en.wikipedia.org/wiki/Community_of_practice
• https://en.wikipedia.org/wiki/Discourse_community
• https://en.wikipedia.org/wiki/Knowledge_community
• https://learnlearn.in/mfc/what-is-mfc/
• MFC Bulletin 383
  

Why Medical College Work Culture is So Horrible

A number of junior residents at Jipmer have raised allegations of mental and physical harassment against the head of department, medicine, and called for action against the senior faculty.
In recent complaints lodged with the Jipmer Dean (Academics), the residents alleged they were subjected to various forms of harassment at the hands of the department head during the three-year PG residency. They sought re-examination of the results of the exit examination on December 23 as they suspected they were deliberately failed in the practical segment by the faculty member.

This is from The Hindu a couple of days ago.

This is just one among the many thousands of such incidents across medical colleges. It would be really difficult to find a medical college which doesn't have harassment and bullying.

When this came up for discussion in a WhatsApp group I am part of, there was an interesting debate. While everyone acknowledged that there is a hierarchical culture in medicine and that this needs to be rectified, there was a slight disagreement on the exacts of how and why.

One argument was that the medical college culture is an extension of the casteist culture outside and that it will go away only when caste based discrimination disappears. To this some disagreed a bit and said it is not the same in institutions like nursing colleges.

Today morning I tweeted: "If you apply the corporate workplace harassment standards to medical colleges, you'll have to fire *all* doctors. That's how horrible that culture is."

I do think there're more issues that lead to the culture in medical colleges apart from casteism. I list down the potential causative factors here.

As you might know, I believe in intersectionality and in the contribution of all these causes (including causes that's not mentioned here) to the problem. The listing here is by no means a suggestion that "X is the reason ABC happens". If you remove X, you'll still have Y, Z, and so many other issues.

There is a lot of work to be done in medical colleges

A medical college (especially in government settings) has a lot of things happening at once. There's out patient department and the rush of patients. There are new admissions being made. There are existing in-patients who need follow-up care. There are constantly new developments (new symptoms or worsening of symptoms, new investigation results). There are plenty of learning requirements to be met. There are procedures to be performed. There are resources that need to be mobilized. There is paper work to be done. There are a lot of people talking to each other, lots of communication and miscommunication. There are duty rosters and handovers. There are emotions and sickness playing beneath all of this.

Almost everything requires to be done as soon as possible too, if not stat.

There is a lot of gap in resources

Often (especially in government settings) the resources required for getting a lot of work done is simply not there. This could be things like medicine, dressing equipments, and suturing material. Or this could be human resources like nurses, specialists, doctors, cleaners, attenders, pharmacists, and technicians.

There is poor spending on healthcare in Indian budget

As a country, India spends much less than what it should on healthcare.

The science of medicine is imperfect and the art of medicine is really hard

Medicine as we practice it has only evolved in the last few decades or so. We still have no idea what's going on in a lot of situations. It's an imperfect science. Biology has a lot of secrets.

Add to that we're dealing with human beings. The art of handling sickness and patient care is always complicated by the intensity of emotions.

Who wants to work hard?

I've left hospital based practice long ago. And I've not been even doing clinic based practice in the last couple of years. Because it is a lot of work.

When there's a lot of work, some people find ways to make it fun. They focus on the learning and growth. Or they focus on the people they're serving. If you can make hard work fun, you can do it for a while.

But it is not possible to do it forever.

Medicine is not fun

After a point, you get a lot of similar patients. There's plateau in learning and drudgery in work.

Even when you find ways to enjoy some of that, you can't enjoy death. People literally die. Despite all of what we do. How do you make death fun?

There are not many options for a change in scenery

It's the same kind of work from the end of MBBS till retirement. You go to hospital. You see patients. Medical college faculties don't even get transfer. You're stuck in the same department of the same building for your entire career.

Lack of skills leads to insecurities

We established that medicine is hard. Many doctors lack skills - be it in the clinic, or in their life. They are sometimes aware of their incompetency too. And some of this manifests as insecurities.

Everyone loves delegation

The best way to get something done while hating it is to delegate it. Patient care is complicated. If it can be delegated, it is less of a headache.

Delegation requires power structures

The easiest way to ensure you can always delegate work is to ensure that there are people "below" you who can do your work at your command. Maintaining a hierarchy is essential for delegation.

Hierarchies are easy to maintain in a hierarchical society

How do we build a hierarchy? We just need to belittle others. There are numerous ways to belittle others when the society has trained many people in things like:

• caste
• gender
• language
• physical appearance

In medical colleges there is a much easier way to belittle people - using their years of experience. Someone who is "junior" can be belittled easily as they will have that much lesser experience.

Individuals can't fight the hierarchy

Because medicine is hard no individual can do it alone. You can't run a hospital by yourself. Especially if you're a junior doctor who is still learning, you absolutely would be terrified of doing patient care without support from seniors. How can you fight someone whose support you need for your work?

There's always something more urgent

There is no space for conflict resolution in medical colleges. Patient care always comes up. There's no time for cooling down. There's no time for empathy.

The individuals who get in are of questionable merit

Most doctors are doctors who have gotten good marks in an entrance examination. This is a test of their memory and cognitive skills in a very narrow domain. This makes the selection process to medical colleges be highly skewed. The skills in various other domains - like social skills, emotional intelligence, empathy - are not regarded at all.

Without these other skills, it is very difficult to even acknowledge when something wrong is happening.

There are not many role models for better culture

Where does one find examples of good work culture in healthcare in India? Very few "alternative" healthcare institutions provide such an exposure. This is not accessible to a wide variety.

Medicine is mostly seen as a job, and not as a passion by many

There aren't a lot of people who think in terms of quality improvement, safety, etc in medicine. For many it is a job. A way to make money and live.

And hundred other reasons

These are what I quickly wrote down. I've not gone to a medical college in a powerless position since about 7 years. I do go to medical colleges very often as an "external" "senior" instructor. I've used this "power" to understand some of the power structures within medical colleges from up close. That has led to some of the insights above.

There are possible many other things that contribute to the mess. Some of the ones above could be wrong too. There are possibly many interventions one can do on many of these problems.