Should doctors be allowed to have a private practice while working in the government is a question that keeps cropping up in policy debates. Not just India, but several countries allow government doctors to have a private practice—a privilege extended only to doctors. Yet, the expert committee appointed by the Andhra Pradesh government on health reform unanimously declared that private practice must be disallowed, inviting sharp comments for and against it. Why is this such a controversial issue?
The Issue
Prior to Independence, there were very few trained allopathic doctors, mostly working in government hospitals. There was little differentiation between public and private. Since then, public policy has permitted private practice on the logic that as the government was unable to remunerate the doctors adequately, they be given ‘non-practising allowance’ and also be allowed private practice, but “outside office hours”. Accordingly, in the olden days, doctors would have private consultation clinics at their residence where people wanting special attention, and having the ability to pay, could go.
Technological advances increased demand for specialists and gave rise to lucrative private markets that could not expand much due to the shortage of specialists, most of whom were working in the government. It was only a matter of time before the arrangement developed cracks. Instances of private nursing homes and clinics set up by the doctor’s family, government doctors working as consultants in private hospitals and doing surgeries in other city hospitals, of specialists working virtually full-time in private hospitals at the cost of patient care and teaching responsibilities in the government institution they were employed in began to surface.
The question of conflict of interest arose with reports of patients being directed to visit the private clinic for better quality treatment and the deliberate undermining of the public hospital, siphoning off of drugs or equipment to own clinics etc. Such fluidity, with no pretence of the need to abide by any ground rules created indiscipline, exacerbated by supervisors themselves becoming a party to the system. This development gained further traction with the introduction of government-sponsored health insurance schemes under which the treating physicians get 30 per cent of the package rate.
But this has been known for long. Such an arrangement is convenient to all. Public policy ‘facilitated’ it by ‘allowing’ private practice even during office hours; in limiting working hours to 2 pm with no compulsions to teach, research etc; making poor investments in providing technology or adequate facilities combined with low salaries to provide the justification to practice outside; and finally, allowing performance-based payments for treatment provided in public or private hospitals under the health insurance programmes.
Andhra Pradesh is no exception to these developments and the impact is clear. Despite 12 years of YSR Arogyasri, the share of government hospitals in total share of funding is less than 30 per cent. Equally disturbing are the outcome reports of work done by specialists during the year.
How does the system of dual practice hurt?
Data show three disturbing sets of conclusions: 1. Suboptimal outcomes in government hospitals and colleges not commensurate with the investment made. In AP, the share of the government in providing outpatient treatment is 14 per cent, and 25 per cent of case of inpatient treatment. Household surveys show that people incur an average of `40,00 for an episode of inpatient treatment in government hospitals, but `30,000 in private hospitals, resulting in nearly ten lakh households getting impoverished due to medical bills.
The experience of AIIMS or Tamil Nadu shows that when the government sector competes with the private sector on quality and price, market prices become more competitive. And finally, when senior management like the hospital superintendent or head of department spend more time in their private clinics, what governance can one expect? Clearly, if the government is to run medical colleges and hospitals, then private practice has to be stopped.
Banning Private Practice: The EC recommendation
The EC recommendation had four components: 1. Raise salaries; 2. Equip and improve the work environment in government hospitals by increasing capital investment; 3. Permit private consultations at defined hours but within the government hospital premises on condition that a proportion of income earned is deposited in the hospital fund and diagnostics, if any, are done only in the hospital laboratories for a fee; and 4. No Arogyasri payments for treatment provided in private hospitals.
If implemented, this would have four results: 1. Quality of care and overall outcomes in government hospitals will go up threefold; 2. It will contain prices in private hospitals; 3. Increase the net availability of doctors, as currently several of the so-called “private” doctors are essentially government ones; and 4. Increase government investment in health. Besides quadrupling the welfare benefits, the optimal functioning of government hospitals as per standards will force private hospitals to also scale up quality of care as per protocols. A competitive market is the best form of regulation.
The crux of the issue is the remuneration. Currently, a specialist in AP earns less than one working in NIMS, SVIMS, AIIMS, or even Tamil Nadu. There is clearly a case for increasing salaries to bring them on a par with others providing a similar level of treatment. Enhancing salaries may entail an additional burden of a maximum of `500 crore per year for government medical colleges, in addition to budgets for improving infrastructure. Some of this can be reduced by a strict reprioritization of current investments, reducing systemic wastage and inefficiencies, and cutting down unnecessary posts, for all of which there is ample scope.
However, such an investment will not only help reduce out of pocket expenditures but also vastly improve quality of care and public service delivery throughout the health system. It is time for making responsible choices and ensuring greater accountability. There will be disruptions, court cases and pressures by those who stand to lose. It is hoped that the AP chief minister will do what is ethically and morally right as the benefits outweigh costs in financial and political terms.