India's private healthcare sector "treats patients as revenue generators" argues a senior doctor in The BMJ today. A second article argues that private healthcare providers in India "are above the law, leaving patients without protection."
Dr Arun Gadre, a gynaecologist in Maharashtra, interviewed 78 doctors across India and found widespread examples of irrational drug prescribing, kickbacks for referrals, and unnecessary investigations and surgical procedures.
Kickbacks for referrals included an example from a general practitioner in Maharashtra, who said that doctors get 30,000-40,000 rupees (£300-400; €450-550; $500-650) for referring patients for angioplasty. A pathologist said that of 150 doctors contacted only three were willing to refer patients for investigations without kickbacks.
Many interviewees mentioned unnecessary investigations and surgical procedures. One example was gynaecologists performing ultrasounds without indications in pregnant women who complain of trivial abdominal pain, then fabricating false reports of cervical abnormalities and advising the women to have cervical stitches, with the pretext of preventing miscarriage.
Few patients request a second opinion, and the doctor does not give them any documents to avoid being found out.
Another example told by a pathologist was referred to as the "sink test." The referring doctor advises a battery of laboratory tests despite no suspicion of pathology. Only a few of the tests are performed, and the extra blood collected is dumped in the sink. Fabricated results are then given in the normal range for all tests that were not performed. The patient pays a large sum, which is shared by the referring doctor and the pathologist.
"These interviews indicate the alarming extent of the deterioration of rationality and ethics in India's private medical sector and the need for stringent, transparent, and mandatory regulation," writes Gadre. Indian medical associations claim that few doctors indulge in unethical and irrational practices, but several interviewees opined that few doctors are unaffected by increasing commercialisation.
Some doctors also pointed to the failings of institutions such as the Medical Council of India and suggested that they should be restructured to include representatives of patients and civil society organisations.
These interviews underscore one fact - paying money does not guarantee good healthcare, writes Gadre. The private healthcare system largely treats patients as revenue generators, without rationality or medical logic.
He says private healthcare in India is "totally unregulated and unaccountable" and believes "the commercial transaction between patients and doctors must be severed."
Ultimately, the only solution for India would be accountable social regulation of the private medical sector, and the movement towards a combination of social insurance and a tax based system for universal healthcare, he concludes.
In a second article, Sunil Nandraj, senior advisor on health systems in New Delhi, argues that private healthcare providers in India are above the law, leaving patients without protection.
He explains that many states have not ratified or do not enforce the central Clinical Establishments (Registration and Regulation) Act 2010, leaving patients exposed to irrational and unethical practices. And he argues that the objections of private providers and doctors' associations don't stand up to scrutiny.
"Current regulatory and accountability mechanisms are not sufficient to ensure quality and prevent negligence," he writes. "Politicians at the highest levels must ensure private healthcare delivery is properly regulated to stop people being subjected to irrational and unethical practices."