“Accreditation of hospitals should be made mandatory”
Soft-spoken and humble, Hinduja Hospital CEO Pramod Lele’s passion for improving health care in India goes beyond the hospital he manages. His own 25-bedded hospital is coming up at Titwala, near Mumbai, a place that lacks a good health care facility for the 90-plus villages in the area. In a conversation with Anuradha Dhareshwar, Lele says that strengthening the PHCs (Public Health care Centres) can go a long way in helping meet India’s health care objectives. |
What are the challenges for the health care industry in a changing socio-economic profile?
A major challenge is that the cost of health care is going up. Secondly, doctors’ charges are also going up resulting in the perception that they are getting greedy. Medical education fees are so high that parents shell out exorbitant amount to educate their children. This cost is later recovered by the doctors from the patients. Medical education has become a lucrative business and in the last few years many private colleges owned by politicians have come up. It is a vicious circle and would require major reforms at the national level to change this.
There is another important reason for the rise in health care costs - the decline of the family doctor system. Earlier, we visited our friendly family doctor in our neighbourhood who gave time to patients, knew the entire medical history of the family members, prescribed simple home remedies and instilled confidence in them. Therefore the cost of medicine was also kept under check. Today, we have a fleet of specialist and consultants for everything. No doctor is happy with a MBBS degree. There is severe shortage of family physicians. The patient-family doctor ratio is highly skewed, which is not a healthy trend.
We often hear the phrase ‘Quality health care for all’. But does the “all” include the masses to whom affordable health care is still a pipedream?
Our motto is ‘Quality health care for all’ and I am proud to say that at least at Hinduja it is followed in letter and spirit. For example, ours is 350-bedded hospital of which 150 are for general ward patients. Of the 150 beds, 70 are reserved for the poor/ weaker section. Anybody with an income of less than ` 25,000 p.a. gets treatment absolutely free; those whose income is between ` 25,000 and ` 50,000 p.a. is charged 50 per cent of the billable amount, so to some extent it makes health care affordable to all. However, you will understand that we are a private charitable hospital which cannot be compared to government or municipal hospitals. Additionally, we also provide treatment at concessional rate to other lower income middle class people, after verifying their source of income. The idea is to have a charity that is not misplaced. Whatever subsidies we offer to general wards patients, we in a way, recover from special rooms. To put it in the right perspective, ‘we don’t make losses’. We upgrade our facilities and equipment every five years. We discard all old equipment completely or give it to philanthropic institutes if they are in good working condition or sometimes avail of the buyback facility from manufacturers.
All the major equipment like CTscan, MRI etc is imported because there is nothing which is equivalent in quality available here or indigenously manufactured. This is where I would appeal to the government to reduce the customs duty on the equipment, ideally make it zero, and also remove octroi which would enable private hospitals to reduce the cost of treatment. Ideally, we should incentivize medical equipment manufacturing companies from abroad to set their units here or support our industrialists to set up facilities in India in collaboration with foreign manufacturers. This will reduce the cost of the equipment to almost half and the hospital can pass on the benefits to the patients thereby making health care affordable.
Is public-private partnership a solution?
Ideally, there should be public private partnership in health care. Incidentally, I had done a study of our PHCs. There are around 30,000 PHCs in India. Each PHC caters to about 15-25 villages. If these PHCs are strengthened, manned properly and have proper equipment, those living in villages would not have to come to cities for treatment. I have had discussions with the American Association of Physicians of Indian Origin (AAPIO) which has 42,000 members and suggested to them to adopt one PHC each. They are willing to adopt. When I approached the government with this idea, they liked it but they do not have the passion or will to implement it. If this concept is taken forward it could bring us funds and also managerial skills. Basically, we need to put a good administrator in place to monitor the working of the PHCs. Today, the government spends around ` 17,000 crore on NRHM including PHCs of which 80 per cent is on salaries. Someone has to monitor that the salaries get translated into efficient medical care. At present, that is not happening. When the PHCs are given under public-private partnership there will be higher accountability from doctors and other staff manning it. Adopting the PPP model will change the rural health care scenario in a very big way. There are also Indian industrialists who are willing to adopt PHCs as a part of their CSR (Corporate Social Responsibility). There are no simple solutions but if someone is ready to take the initiative there is a way out.
How has the emergence of corporate players impacted health care in India? Has it taken away the load off public hospitals?
Emergence of corporate players is a positive development and it has to some extent reduced overdependence on public hospitals. In health care, quality is most important. No doubt when there are corporate players the quality may not be affordable, that is where the government has a role to play, in terms of giving corporate players fiscal incentives to reduce the cost of equipment, improve the efficiency of PHCs, etc., as discussed earlier. There is a demand for better health care and more and more industrialists in India are realising the need for having their own hospitals. It is not from business point alone. The huge demand supply gap in health care is met by corporate players. The mismatch between demand and supply is even bigger in rural areas where the government is giving incentives to those who are ready to provide health care. But to attract private players, the government would have to first provide basic infrastructure like roads, water, power, etc. to run the hospitals.
Does the health care industry focus on preventive health care to reduce the burden of disease in India? How does your hospital contribute towards building awareness and educating the public?
Unfortunately the industry does not focus on prevention. It is mostly curative in nature. At Hinduja, we have at least 30-40 individuals visiting our OPDs everyday for health checkups. This helps in early diagnosis and prevention of bigger ailments to some extent. Similarly, our medical camps are visited by both the healthy and diseased, where our team of doctors provides both preventive and curative care.
As profit motive and sometimes greed takes precedence over service in private health care, people have started losing faith in doctors, hospitals and the entire health care system. How can we correct this?
Here, I feel the media and RTI both have major roles to play. Patients should insist on transparency and demand an explanation where necessary. We are proud to say that at Hinduja, we are very transparent about our billings and give our patients printed tariff list with no hidden costs. We tell our patients in the beginning what is the procedure that will be followed during the treatment and explain to them why certain tests are required. If a hospital does not tell the patient it is the patient’s right/duty to ask. This way you make the doctors and hospitals accountable. A very important thing is that accreditation of all hospitals and nursing homes should be made mandatory. Medical audits will go a long way in checking malpractices and ensuring quality health care.
Having said that, I must say that hospitals and doctors are receiving a lot of negative publicity these days for which the press is mainly responsible. While it is their duty to report what is wrong, how many times do we get to read in papers about the good things that hospitals do, about complex surgeries being performed or new developments in medicine/surgery that would be useful to the public? The press should realise the cascading effect of negative publicity. Doctors may start refusing patients in an emergency and it is the patients who will lose out in the longer run. You cannot take a couple of stray cases of doctor/hospital negligence and keep showing the clipping again and again on television and provoke violence.
Don‘t you agree that the growing apathy shown by the government/ medical fraternity towards patients has led to anger and frustration of the common man coming to the fore?
I agree, but violence against doctors, hospital staff and damaging property is not the answer. People cannot take law into their hands. Similarly, hospitals/doctors cannot turn away patients who have been brought to their doorstep in emergency. This is again inexcusable. We have to remember that all doctors are not demons and the so called demons too have God in them. It would be improper to generalise. I know of so many good doctors who are absolutely sentimental, do not charge their patients, don’t have mobile phones or cars. I would appreciate if the print and audio visual media highlight the achievements of such doctors also. There are also instances where the patient’s family create ruckus only to avoid paying the bill. Without verifying the facts properly, the press should not go on a vilification campaign.
Does the hospital administration make effort at sensitising the staff nurses and labour staff, towards patients as complaints of rude behaviour are quite common?
At Hinduja, we have a ‘Parivaar’ concept. Something unique about this hospital is that none of our services are outsourced like it is in many other private hospitals. The employees, whether it is doctors, nurses or labour staff, they are on our pay roll hence there is a sense of belonging. We too take good care of them, genuinely look into their problems and extend help where possible. We spend huge amount of money on manpower. One of the principles we follow is “work to give”. We take pains to ensure that what is taught in our staff orientation programmes is practised. The staff also undergo refreshers course from time to time. I tell the doctors, the nurses, the ayahs, the ward boys and even the liftman that the patient is the most “impatient” person as he is in pain, so don’t take everything that he says to heart. If patients complain, don’t get upset; look into the complaint objectively and see if the fault can be rectified.
Even before health insurance in India has really taken off, there are umpteen complaints of doctors/hospitals overcharging patients, recommending unnecessary tests/operations and prolonged hospitalisation to inflate bills. How can this be checked?
One way is by transparent billing. Accreditation of hospitals will bring in transparency. Hospitals should have uniform billing system for all – whether the patient is insured, cash paying or corporate. Secondly, hospitals should be open to audit. Those who indulge in malpractices should be singled out and the insurance companies should take necessary action against offenders. The patient too has a responsibility and should be educated on the subject and register a complaint when overcharged. I am a strong advocator of medical insurance. It is a must. When you buy a policy you should have a mindset that you are providing for your unforeseen health care needs for the future and therefore not crib if your money has not been utilised. The other option is ‘self insurance’ where you set aside every year an insurance amount for a future medical emergency. But this option in most cases does not really work unless a person is financially disciplined as there is always a chance that the money gets utilised for some other purpose.
The standard of medical education in India has fallen to the lowest. Bribes, corruption and scams are the order of the day. What can be done to raise the bar and restore order in the medical profession?
It is a reflection of what is happening in the society. We are seeing degeneration of values, so you have the same story of corruption everywhere, in the field of medical education, legal, engineering, so on and so forth. After taking such high capitation fees at least the colleges should have proper infrastructure and faculty in place. Here, the Medical Council of India (MCI), which is the inspection body should ensure that the institutes are not flouting rules or compromising on the quality of education. Similarly, DNB Education (Diplomat of National Board of Education) another regulating body should also pull up its socks to check corruption by hospitals who are charging huge money from post graduate and post doctoral students who want to pursue specialisation in various disciplines after which they can practice anywhere in India. This is turning out to be another money-making racket. As we don’t take any money, we are in demand. Unfortunately even DNB office in Delhi is not organised and efficient. So unless, the inspecting bodies do their jobs with objectivity and there is a political will to bring major reforms, there is no end to this.