Transcript DYNAMICS AND QUALITY OF PRIVATE HEALTH SERVICES IN …
DYNAMICS AND QUALITY OF PRIVATE HEALTH SERVICES IN INDIA Rama V. Baru Associate Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi Paper presented at the International Workshop ‘Public-Private Mix:A Public Health Fix? Strategies for Health Sector Reform in South and South East Asia’ Naresuan University, Phitsanulok, Thailand. 20-22 June, 2007
Private Sector in India
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The private or ‘for-profit’ sector in health services has undergone tremendous growth and diversification during the last six decades of Indian independence.
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From what was largely dominated by individual providers it now includes varied institutional forms ranging from small clinics to nursing homes and tertiary, specialist hospitals.
This is unique to India when compared with any of the other South Asian countries where the private sector is largely dominated by individual practitioners.
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Studies have shown that private practitioners at the primary level consist of a variety that include traditional healers, folk practitioners, herbalists, practitioners of indigenous systems of medicine, allopathic and those practicing allopathy without any formal training.
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There is some evidence to suggest there is considerable amount of cross practice between practitioners, institutions and systems of medicine in the private sector
Private Sector in India
• • The secondary and tertiary levels of care consist of institutions of varying size and ownership patterns. These include nursing homes with bed strength of five to over two hundred depending on scale of operation. • The smaller nursing homes are owned largely by single owners while the larger hospitals are managed as partnerships, private limited, trusts or corporate entities. • This plurality is seen in India and is largely an urban phenomenon but in recent times this segment has grown even in rural areas in the more prosperous states in the country. • Other South Asian countries have little presence of the secondary and tertiary private sector.
India is the major exporter of corporately managed hospital services to several countries in this region and is dominated by the Apollo hospitals group.
Importance of Private Sector
• The importance of analyzing the dynamics of the private sector derives from its significant growth and its utilization for out patient and in patient services across regions and classes. • A number of studies have analysed macro data sets like the National Sample Survey, National Family Health Survey that has shown a considerable reliance on private provisioning for outpatient services across rural and urban areas. These services are provided by individual private practitioners, formally and informally trained.
• The location and distribution of this category of practitioners is mediated by the socio-economic contexts of the population that they serve. There is clearly a clustering of informal practitioners in rural areas where formally trained practitioners do not locate or in urban slums where the poorer sections live.
Structure and Utilisation of Private Sector
• In the case of in-patient services the resort patterns are much more complex with greater back and forth movement between the two sectors. • Private practice by government doctors and the increasing direct and indirect costs in public hospitals has resulted in greater movement between the two sectors.
• There is a clear class gradient in terms of utilization of public hospitals especially in those states where there is a vibrant private sector (Krishnan:1994; Iyer & Sen: 2000; Baru:1998). • In general the poor rely much more on government hospitals while middle and upper classes move in and out of it for consultation, diagnosis and treatment. In the next section we examine the available evidence to analyse the characteristics of the private sector at different levels of care.
Dynamics of the Private Primary Level Providers
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The earliest study that is oft quoted on the rural private practitioner is by Vishwanathan and Rhode. In this pioneering study there was not only an estimate of the numbers but it provided some detail on the background and practices of these practitioners in relation to the management of diarrhoea (Viswanathan & Rhode:1990).
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A number of micro studies in rural and urban areas have shown the presence of a large number of private practitioners both formally and informally trained who provide primary level services (Soman:1992; Bisht:1993; Singh:2005).
Dynamics of the Private Sector
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These practitioners provide services for a variety of minor illnesses including deliveries and are often the only source of treatment in several parts of the country.
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While their presence and role has been widely acknowledged there has been little effort to integrate them into health services delivery.
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There is resistance from the Indian Medical Association against these practitioners and refer to them as ‘quacks’.
Demand for their banning by the IMA
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SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PRIVATE PRACTITIONERS
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Certain important questions arise regarding these practitioners-
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Who are the practitioners?
Where are they located?
What are their practices for treatment?
How do they get their training and what is their interaction with the formal system of health services?
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Table 1 on pg. 5 summarises the findings of major studies on the socio-demographic characteristics of private practitioners.
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There is variation in the caste/class composition across the north and south. Majority have completed high school. Knowledge and skills are acquired through apprenticeship with Qualified Medical Practitioners.
Referral Chain and Linkages Formal and Informal Providers
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Apprenticeship of the RMP with the QMPs, often in the role as a compounder where knowledge and skills are acquired.
After they set up independent practice, the unqualified practitioner refers patients to QMPs and also to government and private institutions. The RMPs act as a pivot of the referral chain for both the public and private health services
Treatment Practices of Private Practitioners
• A few studies show that RMPs do use basic equipments like thermometer, stethoscope and Blood Pressure Instrument in their treatment. • The clinic of an RMP is designed on the lines of a QMP’s clinic, so the ambience is created and maintained with great care. • The prescribing practices are similar to QMPs in that they use a ‘cocktail’ approach to treatment that consists of paracetamol, antibiotics or injections, vitamins and sometimes even a saline drip
Characteristics of Secondary and Tertiary Services
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Studies of secondary and tertiary level private institutions show that they are heterogeneous in terms of size and ownership.
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Their primary focus is on general and maternity services with a few specializations as additional inputs.
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There is a strong link with serving government doctors who act as consultants in these nursing homes and play an important role in ensuring regular patient supply.
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The physical standards of these nursing homes are poor and do not fulfill the minimum standards for space requirement and support staff.
Quality of Private Services
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The working conditions of paramedical and technical staff has been explored by Baru (2004) that clearly points to the gap between the salaries earned by medical and other staff.
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Even the large hospitals pay poorly, employ paramedical staff on a contract basis and have long working hours. This results in large turnover of staff and often there are situations where these nursing homes are short staffed. Kansal’s study supports these findings by examining the salary structure of different paramedical staff across public and private sectors.
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These clearly have consequences for the quality of patient care and questions the popular perception that private sector provides better quality of services as compared to the public sector.
Issues for Reform
• • There is a need to visualize regulation within a systemic perspective. for greater effectiveness.
• Regulation is a complex process and includes recognition of the various actors and their role in the health services, registering and certifying them.
• This includes both informal and formal providers in the health services while recognizing that they are organically interlinked.
Regulations is critical for improving quality of services and also check irrational practices and can be effected through initiatives from the government, self regulation by professional organizations and consumer forums.
Issues for Reform -2
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Evidence regarding the treatment practices of the private practitioners is critical in not only getting insights into the extent of irrational prescriptions but is necessary for planning any training input for upgrading their knowledge and skills. The behaviour and practices of actors at the secondary and tertiary levels of private provisioning and the linkages with public sector employees influence the primary level providers as well.
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Therefore regulation will have to address the different levels.
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The rationale for regulating the private sector arises from the heterogenity of institutions in the private sector; the lack of standardised costs, variability in infrastructure, manpower etc.
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The variability in infrastructure, manpower, services and costs is bound to affect the quality of care in the private sector.
Important to dispel the popular perception that there is a dichotomy between the formal and informal sectors by providing evidence regarding their interlinkages and addressing them through effective policy.
Issues for Reform-3.
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In the Indian context, the National Rural Health Mission recognizes the role of private practitioners and the need to legitimize their role in health services delivery. There is a proposal to train RMPs and TBAs within the NRHM.
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This is an important policy initiative and creates possibilities for creating the context for reforming atleast the primary level of private provisioning.
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However this initiative will only be applicable to the NRHM districts and therefore there is a need to replicate and upscale this model to non NRHM states.
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This could then become the first concrete step towards a more creative policy to regulate the secondary and tertiary levels, in order to improve the quality and accountability of the private health services.