Pause and run the proposed PPP model through a patient’s/caregiver’s lens. The usual gripe against private hospitals holds: all-round over-invoicing, billowing especially during ICU stays when patients are out-of-bounds for caregivers; blood drawn many times over at the same time, expensive medicines administered on the same day/time that impugns maximum prescribed doses; generic drug not administered even when available and branded ones used instead; wanton diagnostic tests, and a plethora of other glaring incongruence that breaches every known medical ethics and moral vocabulary. Hospitals claiming to touch people’s lives indulge in every possible shenanigan and skullduggery to maximise profit. The list is endless. Healthcare today is a smart industry and health-tourism is the buzzword. “Practice two things in your dealings with disease: either help or do not harm the patient” – a part of the Hippocratic Oath – has evanesced, long forgotten. I feel queasy.
Cut to the chase for poor patients. “There will be no reserved beds or no quota of beds for free services,” says the Niti Aayog. “The State Government can refer as many patients as it can up to the capacity available in the Project facility.” How on earth is that going to happen without funds in the government kitty? In effect, the patients fall back on the PHC – now rendered more decrepit before the other PPP-half – for lesser mortals. Two treatment standards, we’re back to square one – India and Bharat!
Interestingly, on the issue of coronary stents brought out in Part-II of this series yesterday, with companies manufacturing coronary stents in India reportedly creating an artificial shortage in market/hospitals in the wake of price capping in February 2017, the Department of Pharmaceuticals (DoP) has, in its order of September 27, 2017, invoked Section 3 (i) of DPCO, 2013 that empowers the Government to “achieve adequate availability and to regulate the distribution of drugs, in case of emergency or in circumstances of urgency or in case of non-commercial use in public interest, direct any manufacturer of any active pharmaceutical ingredient or bulk drug or formulation to increase the production and to sell such active pharmaceutical ingredient or bulk drug to such other manufacturer(s) of formulations and to direct formulators to sell the formulations to institutions, hospitals or any agency as the case may be.”
The DoP has directed the companies manufacturing coronary stents in India to:
- Maintain production/import/supply of the coronary stents;
- Submit a weekly report on coronary stents produced and distributed. They will also submit a weekly production plan for the next week to NPPA and DCGI.
The DoP has also empowered NPPA and DCGI to extend these directions to any other producers of coronary stents in India during this three-month period. This order will be valid for three months (except for Absorb Classic BVS and Absorb GT I BVS stents of Abbott Healthcare) and NPPA and DCGI will recommend withdrawal or extension as the case may be, two weeks before the expiry of the period.
Abbott’s (one of the global behemoths in healthcare) Absorb and Absorb Gt1 Bioresorbable Vascular Scaffold (BVS) is another dodgy saga with safety concerns and issues of clinical trial red-flagged by drug regulators across the world, among them the US, EU, Denmark, Japan and Australia, as widely reported in the media. Adding to this in India was their reluctance to comply with NPPA’s price cap order. To quote a Times of India report of early-September 2017: “A few cardiologists in India, closely identified with promoting these stents, had opposed price control of bioresorbable stents, which sold at about Rs 1.9 lakh before the Rs 31,000 cap imposed by the drug pricing authority. In the US, the price was about $1,500 or about Rs 1 lakh and in Europe it was even lower at about 900 Euros. The use of bioresorbable stents in India was more than five times as high as in developed countries, but there has been no investigation into the safety of patients implanted with these devices.”
Two other different, but related, issues suck. Recall the substantial increase in the Mediclaim premium this year over last year’s rate. So, either the citizen pays directly or the government pays courtesy citizen’s taxes. Add the draft pharmaceutical policy by the department of pharmaceuticals now in the works, with focus not on controlling but on regulating drug prices – quite in line with the Aayog’s proposal to delink the Drug Price Control Order from the National List of Essential Medicines – and you’ll wonder if World Bank’s unseen hand isn’t on an overdrive. Sylvia Karpagam in a recent piece in The Wire has shown the abysmal failure of the PPP model in Rajiv Gandhi Super-Speciality Hospital for tertiary care in Karnataka’s Raichur district and the Karuna Trust for 80 primary healthcare centres across eight States. Intuitively, our Indian healthcare and compassion – a baffling mix of the sublime, the profane and the gratuitous (avarice) – in times of madcap upward material mobility in a consumerist era trumps doctors’ nobility towards patients. Hippocratic Oath is out the window!
My much-harried friend and batch-mate, a Chief District Medical Officer and a subject specialist, works round-the-clock and earns salary that is less than my government pension. Little wonder the rampant absenteeism of government doctors lies in poor remuneration and the urge to indulge in private practice at sufferance of their job responsibility. Couple this with bureaucratic supremacist spirit – a colonial legacy that epitomises our feudal mindset – which belittles their human dignity, and you’ll appreciate their callousness.
The way to go is to incentivise them “commensurate with existing market conditions” (Aayog’s words, not mine!) and create facilities that private entities would with PPP-pinned funds, rid the chalta hai attitude, invoke an arm’s length system to transparently and measurably monitor, and hold them accountable, and watch the changes. I see no reason why, in the same district locale, they’ll bite WB-Aayog’s PPP bait, not the socially-inclined and socially-respectable governments. With doctor’s commissions for diagnostic tests/procedures de-incentivised, the patients will likely be spared the fleecing that many corporate hospitals indulge in today. And compassion will likely coalesce with healthcare; doctors will heal patients – those God’s children on a worldly visit!
This is yet far from complete. For, unsurprisingly, we have lately added another, a fifth estate to our democratic construct not limited to the putative fifth column of immorality and post-truth – beyond the bought-out press, paid news, fake news, advertorial news – that Gauri Lankesh’s death has driven home: ELIMINATION! No need for hyperventilation in entrepôts of raucous cacophony in select TV studios; extirpate the root, so that the voices of such humans are shushed for good. And all this in times of smart histrionics, of bluff and bluster spoken in high octaves! Goebbels sure will be turning and blanching in his grave for his lack of innate smarts! Are we now living in a new Republic of the Fifth Column! Pity the protagonists do not realise ideas are bullet-proof, amenable to traversing time, space and distance – there for keeps!
Academic plagiarism has assumed menacing proportions. The cases are galore – with the list bearing names of many eminences conferred with Padma awards and more. Modesty forbids me from spelling out the names and their tales. But I must state what I, as a member of the UGC-appointed Committee, recently witnessed firsthand: how plagiarism by the former VC of Pondicherry University (subsequently dismissed) has wrought irreparable damage on a university. The malaise is all over. One wonders how much with growing awareness and vigil, plagiarism detection tools like Turnitin and Copyscapes et al, can fix this malaise.
I am inclined to believe (now more or less convinced) that perhaps the deterrence to such potential recklessness lies in tightening governance’s value system. Maybe, an arm’s-length system and an Ombudsman to oversee operations coupled with zero-tolerance to dishonesty and corruption are necessary to bring about ethics in public governance. Yet, given extant obfuscation and opacity, will it be enough to stymie unholy impulses? Will leveraging contemporary technology to bring citizens face to face with governance help? Will such an interface, not ex-ante but ex-post ‘oversight’ governance, aid stakeholders to see for themselves the processes and rationale of decision-making that is already available under Section 4 of the RTI Act, 2005, as proactive disclosure. Never mind the Delhi High Court’s ruling keeping the Attorney General out of the RTI’s purview and the Supreme Court remaining implacably opposed to render itself transparent on personal details of public interest, as evidenced in smothering CIC’s order to part with information under the RTI Act.
Is transparency, then, the answer? Will it help to offer on a platter official document in public domain post-decisions for citizen ombudsman? Will the fear of exposé – disciplinary action and social disapproval for “wrongful acts” – deter unsavory impulses? Possibly, yes; no one likes to be proceeded against; we live on self-respect and dignity amid a 24/7 media. We’ve the technology and we’ve the besetting issue of dishonesty that refuses to die. Sunlight, it seems, is the best and maybe the only disinfectant for public acts.
At the cost of sounding presumptuous, I would say en passant that when I took over as the Controller General of Defence Accounts to helm the Department looking after the financial management and internal audit of the entire Government of India defense budget outlay of approx Rs 3.4 lakh crore, I invoked transparency. All relevant official documents, all pesky issues of officers’ placement and spends from taxpayers’ money were uploaded. It was bloodless; but it had a magical effect. Disaffection with placements was eliminated, with the networkers exposed and running for cover; unnecessary, wasteful expenditures were arrested, with everyone privy to ways of the corrupt and the nepotistic; and with each checkmating the other. Alas, once I moved over to the Ministry of Defence, transparency was given a royal heave-ho and opacity granted its pride of honour!
Leveraging technology to invoke openness and transparency is an option – a culture of transparency seems the viable answer to curb corruption in public life. But it is nuanced, multilayered. It’ll need tempering through accountability, an effective check and balance mechanism, an arm’s length system not open to tweaking by any public functionary, not to forget public discussions to rework and re-engineer the entire architecture of governance processes to introduce the moral vocabulary sorely missing in public governance. Be you ever so high, the law is above you, as the 17th century English church man and historian Thomas Fuller would say. It’ll take time but a beginning must be made. Political will is the key. But will that be forthcoming? And I wonder how relevant our experiential existential formula is today: Experience = CL (Capacity to Learn) x DL (Desire to Learn) x No. of years of service!
The writer, Sudhansu Mohanty, is an acclaimed author and previously served as a Financial Adviser to the Ministry of Defence and Ministry of Environment, Forests & Climate Change.
This article is the final installment in his 3-part series about Ethics in Public Governance.
Tweet at Sudhansu: @MohantyMohanti
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