Points to ponder: a sick system
Nagraj Huilgol

The principle that currently guides our national health care system is that of commodification. The doctor sells his skills and the patient tries to buy his health back. The official policy of liberalisation has only helped rationalise this unfortunate ethos.

The cost of health care is entirely subject to market forces, being based on a fit between the patient’s risk- benefit perception and the doctor’s ability to charge optimal fees. It is, therefore, possible for a doctor in Bombay to make Rs. 40,000 on a coronary bypass operation and a slightly lesser sum on an operation for cancer. A similar scenario prevails in other branches of therapeutics. The credo is to make profits and explain them away in the jargon of the free market.

If the system has not crumbled totally it is because of those unsung, dedicated doctors who continue their work of healing silently and without fanfare.

Another detrimental effect of market forces in the field of medicine may be judged from the distribution across the country of institutions with high- tech equipment. Bombay, for instance, has the largest number of hi- tech imaging centres in the country. There are also more radiation therapy machines here than in the entire state of Uttar Pradesh and their number is steadily increasing.

Thus, while a rich city like Bombay has more facilities than it needs, a poor and backward state like Uttar Pradesh still lacks basic hospital amenities. The profit motive has utterly subverted the provision of equitable distribution of health care. A fundamental imperative of justice has thus been denied to those who are burdened, not only by grinding poverty but also by the travails of disease.

N. G. Huilgol(Dr. N. G. Huilgol is Chief of Radiotherapy at Nanavati Hospital, Bombay. The above letter, with minor modification, is abstracted from the Times ofIndia, 2 June 1994.)

It deserves careful consideration by all those striving restore decency and dignity to the medical profession We must face some questions:

1. What should be the driving force behind a medical doctor? Are we to look upon our services as commodities to be sold at the highest possible price, the consequences to the purchaser be damned; or are we, as professionals, to seek just and fair compensation for our labours and no more keeping in mind the financial and other burdens already borne by our clients - the patients?

2. How are a doctor's fees to be calculated? Traditionally, fees have been based on the duration of training of the doctor; medical qualifications; experience and expertise; degree of technical skill, care, time and energy devoted to the treatment of a given patient and the expense incurred by the doctor during such treatment.

In the past, a senior doctor with a large practice earned enough to live in comfort, educate his children and put some money by for emergencies. The figures quoted by Dr. Huilgol (and they are, if anything, underestimates) now permit such a doctor to own a number of flats in several cities, drive two or more of the most expensive cars, travel abroad several times a year on vacation or for attending meetings and, generally, roll in luxury. Is this to be the enduring ideal for our medical students?

3. Who actually benefits from the innumerable CT and MR scanners and five- star hospitals? And who suffers as a consequence? Hard headed businessmen do not invest in such ventures without ensuring huge returns. Doctors serving them are not driven by altruism. The many public relations exercises undertaken by these organisations speaks volumes on the cut- throat competition between them. The payment of ‘fees’ and other ’ incentives’ by some centres to doctors referring patients to them is wholly indefensible. One example of the ill- effects: Costs of investigation and treatment are constantly and relentlessly being driven upward.

4. Is the tribe of ‘unsung, dedicated doctors ‘flourishing? Would that it were! Many of our bright, promising youngsters are being sucked into the five- star hospital culture. As they gravitate away from teaching hospitals, these institutions will, inevitably, decay with the consequences that are already becoming evident.

(See also Dr. Godfrey’s essay . Editor)

Dr.N. G. Huilgolis Chief of Radiotherapy at Nanavati Hospital, Bombay.